Importance of patient and family satisfaction in perioperative care
Kristen A. Calabroa,b, Mehul V. Ravalc, David H. Rothsteina,b,n a Department of Pediatric Surgery, John R. Oishei Children’s Hospital, Buffalo, NY, USA b Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA c Department of Pediatric Surgery, Children’s Healthcare of Atlanta, and Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA article info Keywords: Patient satisfaction Surveys Communication Multidisciplinary care https://doi.org/10.1053/j.sempedsurg.2018.02.009 1055-8586/& 2018 Elsevier Inc. All rights reserved. abstract As healthcare systems increasingly shift focus toward providing high-quality and high-value care to patients, there has been a simultaneous growth in assessing the patient's experience through patient- reported outcomes. Along with well-known patient reported outcomes such as health-related quality of life and current health state, patient satisfaction can be a valuable assessment of quality. Patient and family satisfaction measures not only affect a patient’s clinical course and influence overall patient compliance, but are increasingly used to gauge physician performance and guide reimbursement. The paucity of standardized measures and the subjective nature of patient and family satisfaction impairs a surgeon’s ability to internalize this feedback and institute actions to optimize clinical care. This review seeks to identify areas to improve patient and family satisfaction with the perioperative experience. & 2018 Elsevier Inc. All rights reserved. Introduction Most contemporary attention on improving healthcare quality and value has been on domains of care influenced by care providers and healthcare systems. Outcomes, specifically for sur- gery, have traditionally focused on mortality, complications, and easily measurable metrics such as length of hospitalization or readmission. The patient perspective has too often been missing from these efforts and now, more than ever, the importance of the patient voice is being recognized. The basic principles of patient- centered care include: access to care, continuity and transition, involvement of family and friends, emotional support, physical comfort, information and education, coordination and integration of care, and respect for patients’ preferences.1 Essential to these principles is the healthcare system and care providers’ willingness to participate in the process and collaborate with patients and major stakeholders in their care. For surgery, a variety of patient- reported outcomes have been identified including satisfaction, quality of life, disability, mood disorder, and pain.2 These domains are often overlapping, highly subjective, and each have measure- ment tools in various stages of development and validation. For the purposes of this review, we will focus on patient and family satisfaction. Patient and family satisfaction are essential quality measures that can inform improvements in the perioperative experience. Patient satisfaction has become an important metric for hospital and physician performance and is increasingly associated with reimbursement.3 Satisfaction not only affects a patient’s clinical course, but can also have an impact on adherence to treatment plans. Poor patient satisfaction increases the likelihood of medical malpractice claims after unfavorable outcomes.4 Patient and care- giver satisfaction involves understanding a complex and dynamic relationship between healthcare providers and patients that includes elements such as expectations, perceptions regarding quality of care, and two-way communication. Professional organ- izations and societies including the American Academy of Pedia- trics (AAP) and the Institute of Medicine (IOM) have prioritized improved patient outcomes through patient-centered care. Cus- tomizing care according to patient needs and values is essential to achieving this goal.5 The struggle to identify factors that influence the overall patient experience is even more significant in the setting of specialty practices.6 Effective evaluation, utilization and application of patient and family satisfaction surveys can improve the overall patient experience. Nonetheless, despite conceptual simplicity, altering and improving care based on such subjective measures has proven to be challenging. Unique challenges in the pediatric patient population n Correspondence to: Pediatric Surgery, 1001 Main St, 3rd Floor, Buffalo, NY 14203, USA. There are unique challenges in the assessment of patient and E-mail address: drothstein@kaleidahealth.org (D.H. Rothstein). family satisfaction for the pediatric perioperative patient. First, Seminars in Pediatric Surgery 27 (2018) 114–120
patient experience must be measured from the perspective of both the child and the adult care provider.5 Often, the fear and anxiety pediatric patients experience can be amplified by their caregiver’s anxiety.7 Second, information should be communicated to the family unit at multiples levels to both obtain informed consent from adult care providers and age-appropriate assent whenever possible. This highlights the importance of assessing baseline health literacy of adult care providers.8 Interestingly, caregiver dissatisfaction with pediatric surgical experiences was related to higher caregiver education levels.5 Other factors associated with lower caregiver satisfaction included longer surgical procedures, surgical complications, and caregivers feeling overwhelmed.5 Caregiver apprehension, in turn, interferes with assimilation of data. Causes for misunderstanding are oral communication of information, use of technical vocabulary, and level of education. It is estimated that 40-80% of spoken informa- tion provided by physicians is immediately forgotten.9 Incomplete or incorrect information transmission may occur when only one caregiver is present during consultation. The anxiety caregivers feel as a result of hearing that their child needs to undergo surgery often leads to distraction and unanswered or forgotten questions.9 Patient and family satisfaction measures Despite the importance of assessing patient satisfaction, there is no standardized process or widely accepted method to measure this outcome.6 One of the most frequently used methods to obtain patient and family satisfaction data is a patient-reported outcome survey. Herein, patients (or caregivers) report their own percep- tions of the impact of disease and treatment as clinical end- points.10 Patient satisfaction surveys are usually focused on the immediate post-operative and post-discharge interval, but longer- term data are lacking and may be insightful. These surveys are doubly complex due to the aforementioned need to assess out- comes from both the child’s and the caregiver’s perspective. The majority of information regarding patient satisfaction is currently obtained from the nationally standardized and publically reported Consumer Assessment of Healthcare Providers and Sys- tems (CAHPS) Hospital Survey. This Centers for Medicare and Medicaid Services (CMS) endorsed tool is the first to allow valid comparisons to be made across hospitals locally, regionally and nationally.11 Despite development of alternative surveys to garner patient satisfaction feedback, CMS regulations over the types of surveys that hospitals are allowed to administer render the implementation of new surveys difficult. Thus, many healthcare systems have turned to less conventional methods to collect information using commercially-available internet tools such as SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Currently available satisfaction surveys are not specific to peri- operative patients. Furthermore, many of the existing surveys are intended for patients who were hospitalized rather than treated as outpatients. The CAHPS Hospital Survey focuses on quality assessment relating to communication between physicians, other care pro- viders, and patients. This survey can be completed via mail, telephone, mail with telephone follow-up, or interactive voice recognition prompts. Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ) to develop and test the CAHPS survey.11 In 2006, the survey was implemented with the first public reporting of results in March 2008.11 In October 2014 Boston Children’s Hospital created the pedia- tric CAHPS survey.12 This survey asks caregivers to report on both their child’s inpatient experience and their own experience with their child’s inpatient stay. The survey was designed to measure the patient-centeredness of hospital care for patients less than 17 K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 115 years old. Questions focus on communication, hospital environ- ment, appropriateness of care, pain management, and other domains that caregivers viewed as important aspects of their child’s care. The pediatric CAHPS survey has 62 items, takes approximately 15 minutes to complete, and feedback is organized into five specific areas: communication with caregivers, commu- nication with children, attention to safety and comfort, hospital environment, and global rating. The survey is administered via phone or mail. Due to the duration and the inability to reach all patients, response rates tend to be low, and the pediatric CAHPS does not take capture patients who have same day surgery. Press Ganey patient experience surveys combine the required CAHPS questions with scientifically-developed patient-centered questions to provide the most comprehensive view of the overall patient experience.13 While the CAHPS survey measures patient experience (how often a service was provided), additional Press Ganey questions reveal important qualitative details (how well a service was provided), enabling for a more balanced perspective of patient care within your organization.13 There are other propri- etary survey tools available in various stages of development and validation to address outpatient experiences and various specific aspects of care. Further standardized measurement tools for patient experience and satisfaction are lacking.5 Such tools could standardize the currently heterogeneous data collected, assist in research and quality improvement efforts, and allow findings to be more valid and generalizable.5 Patient satisfaction and pediatric surgery The IOM has defined patient-centered care as care that is respectful of and responsive to individual patient preferences, needs, and values while ensuring patient values guide clinical decisions.14 The AAP recommends that patient- and family-cen- tered care be incorporated into all aspects of children’s surgical perioperative experiences.15 This patient-centered focus has become essential to the streamlining everyday operative care plan by decreasing patient confusion and increasing communication between care providers and between patients and care providers. While paramount, specific techniques to improve communication do not exist. Many hospitals have developed competency curricula focused on improving communication skills such as active listen- ing, responding to patients' feelings with empathy and respect, and negotiation.16 There are a multitude of additional, non-clinical factors, such as staff friendliness and facilities/amenities that can influence the overall patient experience.6 Care providers can further build the patient-physician relationship by showing empathy, by having direct eye contact, appropriate facial expressions, engaging body language, as well as appropriate touch.17 Actively listening, engag- ing body language and appropriate touch can all be further improved through training sessions and easily implemented in a pediatric surgery clinic.6 Overall satisfaction is correlated with the child’s impression of the nurse as friendly and the nurse and doctor as transmitting serenity.18 Pooled results demonstrate associations among satisfaction and continuity of care, provider interpersonal behavior, the care team comforting the child, explaining what is going on in the surgical process, and answering questions.5 These concepts are often taught in medical school but require further attention as physicians travel deeper into their practices. Improvements upon patient and family satisfaction can be made with each patient-family-provider interaction.6 It is not uncommon for a lack of provider-patient communication to leave patients feeling unclear, anxious, and uncertain. Patients may
question their provider’s decision-making ability. Due to the complexity of diseases and disorders in a pediatric population, patients encounter a variety of specialists and meet multiple members of the care team during each visit.6 A unified care plan can instill a confidence in the solidarity of care team and conveys clear provider to provider communication. Additional improve- ments to patient/family satisfaction can occur when effectively engaging the patients and their families in discussions and plans pertaining to goals of care (see Heiss and Raval’s comments in their discussion of patient engagement in this issues of Seminars in Pediatric Surgery). Significance of patient and family satisfaction Unsolicited patient observations of surgeons have been shown to be associated with increased risk of surgical and medical complications. Cooper et al. used data from 7 academic medical centers participating in a patient advocacy reporting system and assessed surgical outcomes in the National Surgical Quality Improvement Program.19 They found that the adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. They concluded that efforts to promote patient safety should continue to focus on surgeons’ ability to communicate respectfully and effectively with patients and other medical professionals. Patient and family satisfaction can also influence a patient’s clinical course by impacting adherence to treatment plans. Improved patient care is the most important benefit of optimizing patient and family satisfaction, but there are additional factors that physicians must also consider. Low satisfaction has been associ- ated with the likelihood of medical malpractice claims after unfavorable outcomes.4 Negative experiences may affect referral patterns, community and hospital rankings, and possibly even reimbursement.20 Both federal government and health insurance plans are utilizing quality of care as a central measure for which hospitals are paid, through the value-based purchasing program.21 In October 2012, the CMS began withholding hospitals’ Medicare reimbursement based on their quality performance. Thirty percent of the decision was based on how well the hospital scored on the CAHPS survey.22 Recommendations We have summarized recommendations for improving patient and parent satisfaction in the accompanying Table 1. They are divided into Communication, Informed Consent, Perioperative Obstacles, Outpatients, Inpatients and Multidisciplinary Rounds, Physician Training, and Discharge. Communication Although the perioperative experience should be viewed as a complete experience, it is important to focus on the factors affecting each of the phases of care: preoperative, intraoperative, and postoperative. The major thrust of communication centers on creating therapeutic alliances between patient/family and the care provider. Communication can take many forms, and reinforcing oral communication that is most common in the office setting with written and even internet/video-based formats can be quite helpful. K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 116 Informed consent The informed consent process is frequently lacking in detail, discussion of alternative treatments, and in-patient comprehen- sion. Checklists and iterative conversations can be helpful. Perioperative family obstacles Parents can feel helpless while their child is away from them in an operating room or procedure suite. Providing comfortable physical space and frequent updates can help alleviate some of these feelings. Outpatient surgical patients Clinical practice guidelines and the provision of web-based and written information can be helpful to families, as are post- operative phone calls early in the recovery time period. Surgical inpatients and multidisciplinary, family-centered rounds, young physician training Multidisciplinary, family-centered rounds can be very helpful for inpatients and families, as well as care teams. They engage families, reduce communication errors, and allow for real-time teaching and problem-solving. An additional benefit may be found in the training of residents, who might be observed during their interaction with care teams and patients and families. Discharge Streamlining the discharge process through encouraging patient/family engagement, point-of-service nursing autonomy and provision of written communication has multiple benefits, including reducing unnecessary bed utilization, allowing families to return to their usual home environments, and providing the appearance of organization. Discharge checklists have proven useful to simplify the process (Fig. 1).23 Future directions Application of integrated technology to improve perioperative satisfaction is being more frequently utilized. One center set out to improve intraoperative communication using paddle pagers, dig- ital pagers, and nursing liaisons.3 Families were given a pager at check in, and within the electronic medical record, a system was created so four standard messages or one free text option, limited to eighty characters for clarity, could be sent to the pagers. Update reminders appeared for the circulating nurse at timed intervals at which point the nurse could select an appropriate standardized or custom message. Six months after initial implementation, surveys were administered to patient’s families, nurses, and surgeons to assess the effects of the new intraoperative paging system. Surveys noted an overall trend that the pager was easy to use, family members felt comfortable leaving the waiting room without concern of not receiving updates, and all reported receiving information they wanted during surgery. Press-Ganey survey scores validated the findings. Eighty-one percent of nurses sur- veyed responded to the survey, none of whom reported difficulty reaching families. Ninety-six percent believed families were get- ting desired information and ninety percent believed the paging system brought value to their patient’s family experience. Many believed the system also allowed them to stay within their work- space more often than before. Surgeons had a seventy-six percent
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 117 Table 1 Recommendations for improving patient and parent satisfaction. Recommendation Importance Implementation Communication Initiate communication early. Communication and trust are key foundations in building a successful physician-patient relationship, particularly prior to surgery.6 Establish a basis for strong communication at the first visit. Data must be understood and integrated by the patient/ their parent despite anxiety.9 The benefits of strong communication between surgeons and their patients’ families reaches beyond anxiety reduction and improved patient satisfaction score.3 Be knowledgeable/share knowledge. Studies correlate patient’s trust with patient’s perception of physician communication, level of interpersonal treatment, and perception of physician knowledge.26 Create a fluid dialogue between physician, patient/patient’s families in order to share information and unify all parties with vested interest. Shared knowledge enables formation of a unified understanding and a “therapeutic alliance” for making well informed medical decisions.3 In the operative setting, perception of the care team as knowledgeable and caring was correlated with higher satisfaction scores.5 Involve the patient and their parents in the treatment plan. The crux of the patient care experience is measured by the parents’ involvement in treatment as well as ultimate medical decision making.5 Continue active communication, even during high-anxiety periods, that involved the patient and their parents. A healthy patient-physician relationship, indicated by a patient’s likelihood to recommend the care provider and patients’ confidence in the care provider, were major deciding factors in patient.6 Provide personalized preoperative leaflets. Personalized preoperative leaflets have improved comprehension-memorization, information quality, and parental satisfaction by reinforcing the feeling of receiving quality care, while significantly decreasing anxiety. Use a combination of verbal and written information. Written information should supplement spoken information and is no way a substitute for verbal information.9 9 Get family and patient input in order to personalize to the patient’s specific needs. Preoperative literature proved to be most effective when it was created with the family’s and patient’s needs and goals in mind and is patient specific. Implement therapeutic play, video educational tools, and supplemental home materials. Evaluating the care experience of parents and children with such methods demonstrated a decreased anxiety in both children and parents and significantly higher patient satisfaction.5 Utilize various methods in order to achieve higher satisfaction. Take time, answer all post-operative questions. More likely to relieve some anxiety surrounding the surgical procedure and may even prevent many postoperative phone calls. Designate time for postoperative questions. Effective communication can also improve health outcomes including function and pain control.3 Manifest proper body language and expression. Non-clinical factors, such as physician-patient relationship, staff friendliness, and environment of the practice, are particularly influential in determining the overall patient experience.6 These skills can all be further improved through training sessions and can be easily implemented.6 Build the patient-physician relationship by showing empathy, by having direct eye contact, appropriate facial expressions, engaging body language, as well as appropriate touch.17 Overall satisfaction is correlated with the child’s impression of the nurse as friendly and the nurse and doctor as transmitting serenity.18 There are associations among satisfaction and continuity of care, provider interpersonal behavior, the care team comforting the child, explaining what is going on in the surgical process, and answering questions.5 Informed Consent Utilize an informed consent checklist The informed consent process is suboptimal.27 These discussions should be agreed upon prior to providers discussing surgical procedures with patients. Inconsistencies during informed consent discussions are common. Resident education should include effectively initiating and properly obtaining informed consent. Each surgeon’s unique variation leads to a lack of consistent and standardized information being delivered making it difficult for patients to make an informed decision.27 After implementation of an informed consent checklist the overall average satisfaction score significantly increased for general surgery.27 Perioperative family obstacles Provide clean, quiet, comfortable Surgical Waiting Areas Surgical waiting areas are frequently criticized on Press- Ganey satisfaction surveys, with many families expressing dissatisfaction due to lack of comfort or overcrowding.3 Assess waiting areas and renovate if necessary.
Table 1 (continued ) Recommendation Importance Implementation These factors contribute to many families seeking out an alternative place to wait and therefore making them difficult to find after an operation. Have a reliable communication system for family updates during an operation. 3 This system will additionally allow for family tracking after surgery Reliable perioperative family communication is crucial for completion. optimal patient satisfaction but is hindered by difficulty locating families.3 Have postoperative family discussions and answer questions. Updates during the operation help calm anxieties and allow the family to feel connected to the surgery. Use of an intraoperative paging system. Answer all questions, utilize intraoperative photos or diagrams as able. Outpatient surgical patients Provide additional written postoperative information Time spent addressing questions and concerns ultimately leads to improved patient satisfaction as well as better adherence to discussed treatment plans due to an increased understanding of the goal and the steps needed to reach that goal. Distribute postoperative information packets upon discharge. Reduces anxiety, increases understanding, and improves patient and family satisfaction. Make routine postoperative follow up telephone calls. Additional written postoperative information is an effective way to deliver accurate information allowing patients and family members to reference it should further questions arise. Postoperative telephone calls related to high satisfaction Physician or designated office staff to perform postoperative scores.5 telephone call. Surgical in-patients and multidisciplinary, family-centered rounds Recommendation Importance Implementation Patient rounds should be family-centered. Family-centered rounds create a sense of common purpose, a sense of personal and collective power, active listening, shared responsibility for leadership, translucency to the problem-solving process, and a feeling of respect with a sense of collaboration and team spirit.28 There should be collaboration between families and health care providers, and family to family networking and support should be facilitated.28 The use of interdisciplinary teams helps improve patient care, communication, safety culture, and overall patient satisfaction6. Create ground rules for rounds to significantly decrease rounding time. Family-centered rounds were associated with higher parent satisfaction, consistent medical information and care plan discussion, with no additional burden to use of health services.29 Poor communication has been identified as a major contributor to adverse events and compromised patient outcomes.30 Multidisciplinary family centered rounds should be incorporated into the training aspect for future and young physicians. Multidisciplinary family-centered rounds are not only Attending physicians should make sure to include residents important to patient care, but are additionally significant in and students during multidisciplinary rounds and the training of our future surgeons and other care providers. constructively critique them so that they can improve The Accreditation Committee for Graduate Medical their skill set. Education includes among residency training core competencies the ability to provide family-centered patient care that is culturally effective, developmentally and age-appropriate, compassionate, and effective.31 Multidisciplinary family-centered rounds provide a venue for direct observation of trainees with the chance to observe communication between the attending and families where one can witness professionalism, compassion and respect, and improve physical examination skills.32 Discharge Identify discharge needs early. Allows for efficient and effective discharge and is vital to quality care and patient satisfaction. Discuss and address needs early. Decreased length of stay and added cost savings are associated with same day discharge. Additionally, patients reported high satisfaction with their hospital experience.33 Increasing communication between the healthcare team and patients leads to positive clinical outcomes, improvement in patient’s perception of communication regarding medications, discharge information, and the likelihood to recommend the hospital.34 Utilize discharge needs assessment tools/ checklists outlining discharge tasks Staff may perceive workload decompression, as tasks are no Identify and address specific needs for discharge as they are longer left for completion on the day of discharge. noted. Allows families to discuss their needs well in advance of discharge.35 K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 118
response rate all of whom reported improved intraoperative communication and ease of post-operatively finding families. Researchers in Shanghai, China recently used smartphone application technology to assess patient satisfaction.10 Their small study of ten patients, five caregivers, and two nurses, focused on patient-reported outcome surveys. Their group believed smart- phone applications have the potential to collect patient reported outcome data with high efficiency and effectiveness. This use of technology can be helpful especially in low-socioeconomic status groups and low-income countries where there are more smart- phone users than computer users. They also felt mobile surveys may be the best for reaching children who frequently use smart- phones and for collection of longitudinal data that require repeated survey completion. They altered patient-reported out- come survey questions to be more age specific, with caregivers answering for children 5-7 years old and allowing older pediatric patients to answer for themselves.10 This group subsequently created an interactive application capable of reading the questions aloud to help patients with basic literacy difficulties complete the survey. Using age-appropriate questions, decreasing survey length, removing literacy barriers, and making the smart phone accessible surveys may improve satisfaction survey response rates and collection of accurate data. Some centers are utilizing virtual reality for preoperative patients as well as during some surgical procedures. Distraction and virtual reality are an effective adjunct to pharmacological interventions in reducing pain.24 Virtual reality allows patients to be immersed in a relaxing, peaceful environment.25 It represents a noninvasive way to reduce preoperative stress levels with no side effects and minimal need for additional medical or paramedical staff.25 Ford et al. studied ten adult patients that used virtual reality during burn care dressing changes in an outpatient clinic setting, after which they completed a satisfaction survey and individual qualitative interview.24 Quantitative and qualitative results from both patient and provider perspectives consistently supported the feasibility and utility of applying low-cost virtual reality technology in this setting.24 Application of integrated technology and other non-conventional intervention and meas- urement tools are becoming increasingly necessary in achieving patient satisfaction and improving the perioperative care experience. Conclusion Patient and family satisfaction are important quality measures, continuously being evaluated and weighed to improve the peri- operative experience. They repeatedly manifest their importance in evaluating hospital and physician performance, in part evi- denced by their increasing prominence in reimbursement schemes. Understanding the forces driving patient satisfaction and experience of care can help improve the patient’s clinical course and adherence to the discussed treatment plans. Conduct- ing and appropriately interpreting patient satisfaction surveys in the pediatric population provides additional challenges due to the Medical discharge criteria defined upon admission and noted in electronic health record K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 119 Patient Patient meets discharge discharged criteria within two hours of meeting discharge criteria (goal) Fig. 1. Discharge checklist. target’s age and the additional need to evaluate caregiver experi- ence. Many satisfaction surveys provide only an illusion of captur- ing the patient and caregiver voice. Healthcare providers and researchers must develop and validate novel methods to capture patient expectations, perceptions, and satisfaction to evaluate the services we provide. Advances in technology and utilization of electronic health records may improve collection of satisfaction data and facilitate accurate assessment of this critical outcome in children’s care. References 1. Picker Institute. Principles of Patient-Centered Care. http://pickerinstitute.org/ about/picker-principles/; 2018. 2. Girard N. Evidence appraisal of Waljee J, McGlinn EP, Sears ED, Chung KC. Patient expectations and patient-reported outcomes in surgery: a systematic review: surgery. 2014;155(5):799-808. AORN J. 2016;103(2):250–255. 3. Wieck MM, Blake B, Sellick C, Kenron D, DeVries D, Terry S, et al. 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