International Journal of Health Care Quality Assurance Trends in patient perception of hospital care quality Pierre Batailler Patrice François Van Mô Dang Elodie Sellier Jean-Philippe Vittoz Arnaud Seigneurin Jose Labarere
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IJHCQA 27,5
Trends in patient perception of hospital care quality Pierre Batailler
414 Received 1 February 2013 Revised 19 June 2013 Accepted 25 October 2013
Infection Control Unit, Grenoble University Hospital, Grenoble, France
Patrice Franc¸ois Quality of Care Unit, Grenoble University Hospital, Grenoble, France
Van Moˆ Dang Department of Medicine, Division of Geriatrics, Grenoble University Hospital, Grenoble, France, and
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Elodie Sellier, Jean-Philippe Vittoz, Arnaud Seigneurin and Jose Labarere Quality of Care Unit, Grenoble University Hospital, Grenoble, France Abstract Purpose – The purpose of this paper is to investigate trends in patient hospital quality perceptions between 1999 and 2010. Design/methodology/approach – Original data from 11 cross-sectional surveys carried out in a French single university hospital were analyzed. Based on responses to a 29-item survey instrument, overall and subscale perception scores (range 0-10) were computed covering six key hospital care quality dimensions. Findings – Of 16,516 surveyed patients, 10,704 (64.8 percent) participated in the study. The median overall patient perception score decreased from 7.86 (25th-75th percentiles, 6.67-8.85) in 1999 to 7.82 (25th-75th percentiles, 6.67-8.74) in 2010 ( p for trend o0.001). A decreasing trend was observed for the living arrangement subscale score (from 7.78 in 1999 to 7.50 in 2010, p for trend o0.001). Food service and room comfort perceptions deteriorated over the study period while patients increasingly reported better explanations before being examined. Practical implications – Patient perception scores may disguise divergent judgments on different care aspect while individual items highlight specific areas with room for improvement. Originality/value – Despite growing pressure on healthcare expenditure, this single-center study showed only modest reduction in patients’ hospital-care perceptions in the 2000s. Keywords Patient perception, Public health service Paper type Research paper
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 414-426 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-02-2013-0014
Introduction Patients’ hospital quality perceptions complement standardized care quality process measures and safety indicators (Fenton et al., 2012; Isaac et al., 2010). Patient satisfaction surveys are used in quality improvement incentive programs and may help consumers make more informed choices when selecting hospitals (Goldstein et al., 2005). Hence, inpatient discharge surveys have been carried out with various purposes ( Jha et al., 2008; Bruster et al., 1994; Charles et al., 1994; Jenkinson et al., 2002; Antoniotti et al., 2009). During the last decade, major healthcare and social reforms involved France’s public hospital staff, including gradual transition to a diagnosis-related group-based prospective payment system in 2004 (Chevreul The authors thank Linda Northrup, English Solutions (Voiron, France), for her assistance in preparing and editing the manuscript.
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et al., 2010) and enforcing legislation restricting the working week to 35 hours for full-time employees in 2002 (Chevreul et al., 2010; Woodrow et al., 2006). Moreover public hospitals faced nursing shortages, low investment, saturated emergency departments and growing discouragement among healthcare teams (Dorozynski, 2002; Fauconnier, 2009). Although 65 percent of French citizens were highly satisfied with their healthcare according to a survey carried out in 2004, some authors questioned whether France’s healthcare providers could keep their patients happy (Degos et al., 2008). To our knowledge, few studies have monitored patients’ hospital quality perception trends during the 2000s (Elliott et al., 2010), so we investigated trends in quality reported by patients discharged from a large public hospital in France between 1999 and 2010. Specifically, we investigate whether patient perception was sensitive to changes in hospital-service quality. Methods Study design We analyzed original data from 11 cross-sectional surveys involving discharged patients from Grenoble University Hospital between 1999 and 2010. Although the survey was carried out annually, it could not be performed in 2008 for logistical reasons. The survey received the French Data Protection Agency’s approval (Commission Nationale de l’Informatique et des Liberte´s, Paris, France). Study site Grenoble University Hospital is a full-teaching hospital with 1,347 acute-care beds serving a predominantly urban population (450,000). It is the regional referral center for the French Northern Alps. Grenoble University Hospital had 58,412 acute-care stays, with a 6.7-day mean length of stay (LoS) in 2010. Staff comprised 1,700 nurses, 420 physicians and 210 medical residents (full time equivalents). Patients Depending on the year, we recruited between 1,480 and 1,520 patients discharged from acute-care during a two-week period in April. Medical, surgical or obstetrics and gynecology inpatients staying more than 24 hours were eligible if they were discharged to their home or to a nursing home. Patients transferred to other acute-care hospitals and those discharged to post-acute-care facilities were not eligible. There was no diagnosis limitation to patient selection. Data collection Information on baseline patient demographics (i.e. age and gender) and hospital stay (i.e. emergency department admission, department type, discharge disposition and LoS) was retrieved from the hospital’s database. Additional patient socio-demographic data including marital status, education level, occupation and patient perceptions were collected using a standardized survey instrument (development and psychometric properties reported in detail elsewhere – Labarere et al., 2000, 2001, 2004). The questionnaire included 29 items covering six key hospital quality dimensions: nurses’ interpersonal and technical skills; information; continuity of care; physicians’ interpersonal and technical skills; convenience; and living arrangements (Appendix). Each item was rated on a four-point Likert scale ranging from strongly disagree (1) to strongly agree (4). The questionnaire was mailed to patients within two to four weeks of discharge along with a prepaid envelope and a cover letter guaranteeing patient
Perception of hospital care quality 415
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416
confidentiality and encouraging them to participate. A follow-up letter was sent to non-respondents two weeks later. Patient perception scores For each patient, we computed six subscales, each corresponding to a key hospital care quality dimension and an overall score, based on his/her 29-item ratings (Labarere et al., 2001, 2004). Each subscale score was computed by summing individual items pertaining to the dimension. Subscale and overall scores were standardized, ranging between 0 and 10, with higher scores denoting a better rating. Subscale scores were coded as missing if more than half the items omitted values. Questionnaires with more than six missing values (i.e. missing values 420 percent) were excluded from the analysis. This is the same strategy used in the instrument’s original development and validation study (Labarere et al., 2001, 2004). Statistical analysis Categorical variables were reported as numbers and percentages and continuous variables as median and 25th and 75th percentiles or mean and standard deviation. Differences in baseline characteristics and patient perception scores were compared using the non-parametric Kruskal-Wallis test for continuous and the w2 test for categorical variables. In uni-variable analysis, temporal trends in overall and subscale perception scores were examined using a non-parametric Wilcoxon-type test for trend (Cuzick, 1985). We assessed the linearity assumption for trends in patient perception scores by checking for improvement in uni-variable model fit after adding fractional polynomial functions. We performed multi-variable logistic regression analysis to examine the independent associations between survey year and the odds of reporting overall perception score equal to or higher than eight. We assessed the log linearity assumption by performing likelihood-ratio tests for nested model specifications. To account for potential confounding; e.g. changes in respondent baseline characteristics, our estimates were adjusted for age and gender. Two-tailed p-values o0.05 were considered statistically significant. All analyses were performed using Stata version 11.0 (Stata Corporation, College Station, TX, USA). Results Of 16,516 patients surveyed, 10,704 (64.8 percent) returned the questionnaire. The response rate decreased from 70.2 percent in 1999 to 58.0 percent in 2010 ( p for linear trend o 0.001). After excluding 688 questionnaires with more than six missing values, the analytical sample was 10,016 respondents. Overall, the respondents’ mean age was 52 years, 5,241 (53.3 percent) were male and 4,143 (41.4 percent) underwent a surgical procedure (Table I). In 2010, respondents were older, were more likely to present to the emergency department and to be hospitalized in medical departments, had shorter stays and were more frequently discharged to home compared to respondents surveyed in 1999 (Table I). The median overall patient perception score was 7.74, with median subscale scores ranging from 7.5 for the information, convenience and physicians’ interpersonal and technical skills dimensions to 8.33 for the continuity dimension (Table II). In the uni-variable analysis, overall patient perception and living arrangements subscale scores decreased between 1999 and 2010 (Table II). No other significant linear trends were found and the linear assumption was rejected for nurses’ interpersonal and technical skills subscale score.
1999
2001
2002
2003
2004
2005
2006
2007
2009
2010
All
311 (33.3)
483 (51.7) 403 (43.1) 49 (5.2) 840 (89.8)
323 (32.7)
504 (51.1) 427 (43.3) 56 (5.7) 860 (87.1)
829 (89.6)
470 (50.8) 408 (44.1) 47 (5.1)
322 (34.8)
797 (89.9)
449 (50.6) 396 (44.6) 42 (4.7)
282 (31.8)
869 (89.3)
482 (49.5) 463 (47.6) 28 (2.9)
334 (34.3)
764 (88.7)
445 (51.7) 386 (44.8) 30 (3.5)
274 (31.8)
373 (42)
345 (42)
0.002 0.20 0.01 0.25
p
779 (89.3) 846 (93.8) 780 (88.4) 755 (92.4) 8,962 (89.5) o0.001
o0.001
3,535 (35.3) o0.001
441 (50.6) 587 (65.1) 551 (62.5) 529 (64.8) 5,447 (54.4) 406 (46.6) 293 (32.5) 296 (33.6) 252 (30.8) 4,143 (41.4) 25 (2.9) 22 (2.4) 35 (4.0) 36 (4.4) 426 (4.3)
281 (32.2) 360 (40)
50.8 (24.3) 51.9 (24.4) 50.9 (24.5) 51.0 (24.4) 51.7 (24.8) 53.9 (24.9) 53.4 (23.9) 54.3 (24.0) 53.6 (23.4) 53.0 (22.1) 52.3 (24.2) 548 (57.0) 483 (53.3) 476 (52.7) 447 (51.9) 518 (54.9) 473 (55.1) 471 (54.6) 467 (52.3) 455 (51.6) 422 (51.7) 5,241 (53.3) 138 (14.3) 123 (13.4) 138 (15.2) 114 (13.1) 128 (13.3) 112 (13.2) 94 (11.1) 143 (16.2) 112 (12.9) 99 (12.3) 1,341 (13.6) 5 (2-10) 5 (3-11) 5 (2-10) 5 (3-10) 5 (2-10) 4 (2-10) 4 (3-9) 5 (2-9) 4 (2-9) 5 (2-9) 5 (2-10)
2000
Notes: n ¼ 10,016. aValues were missing for gender (n ¼ 184) and marital status (n ¼ 179)
Age, mean (SD), year 51.0 (24.5) Male gender, n (%) 481 (50.9) Single, n (%) 140 (14.6) Length of stay, 5 (3-10) median (25th-75th percentiles), d Admission to the 330 (33.9) emergency department, n (%) Department, n (%) Medicine 506 (51.9) Surgery 413 (42.4) Gynecology and 56 (5.7) obstetrics Discharged to 843 (86.5) home, n (%)
Characteristicsa
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Perception of hospital care quality 417
Table I. Respondent characteristics by study year
Table II. Overall and subscale patient perception scores by study year
8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.78 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.89) 7.86 (6.67-8.85)
8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 8.33 (6.67-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.89) 7.98 (6.78-8.85)
2000 (n ¼ 987) 8.33 (7.14-9.33) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (5.83-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.33) 7.78 (6.67-8.74)
2001 (n ¼ 935) 8.10 (6.67-9.33) 7.50 (5.56-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.33) 7.70 (6.44-8.74)
2002 (n ¼ 925)
Notes: aData are given as median (25th-75th percentiles); b p for heterogeneity
Overall
Convenience
Physicians’ interpersonal and technical skills Living arrangements
Continuity of care
Nurses’ interpersonal and technical skills Information
1999 (n ¼ 975) 8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 8.33 (6.67-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.89) 7.82 (6.67-8.85)
2003 (n ¼ 887) 8.10 (6.67-9.44) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (5.83-9.17) 7.50 (6.11-8.89) 7.50 (6.67-8.33) 7.69 (6.53-8.71)
2004 (n ¼ 973) 8.10 (7.14-9.05) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (6.67-9.17) 7.33 (6.11-8.67) 7.50 (6.67-8.89) 7.70 (6.55-8.69)
2005 (n ¼ 861) 8.10 (6.67-9.05) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (5.83-9.17) 7.33 (6.11-8.67) 7.50 (6.67-8.33) 7.67 (6.44-8.62)
2006 (n ¼ 872) 8.57 (6.67-9.05) 6.67 (5.56-9.17) 7.78 (6.67-9.17) 7.50 (5.83-9.17) 7.22 (6.11-8.89) 7.50 (6.67-8.33) 7.70 (6.55-8.69)
2007 (n ¼ 902)
8.10 (6.67-9.05) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.22 (6.11-8.33) 7.50 (6.67-8.33) 7.70 (6.44-8.62)
2009 (n ¼ 882)
8.33 (7.14-9.44) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.50 (6.11-8.89) 7.50 (6.67-8.89) 7.82 (6.67-8.74)
2010 (n ¼ 817)
418
Perception score
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8.10 (7.14-9.44) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.33) 7.74 (6.55-8.74)
All (n ¼ 10,016)
o0.001
0.99
o0.001
0.99
0.99
0.99
0.03b
p for trend
IJHCQA 27,5
Perception of hospital care quality 419
Discussion This cross-sectional survey pooled analysis totaling more than 10,000 respondents found little evidence for a decreasing trend in hospital quality perception between 1999 and 2010. After adjusting for changes in baseline respondent characteristics, only modest reductions in overall and subscale perception scores were found in the second half of the 2000s, with estimates in 2010 reaching levels comparable to those observed at the beginning of the decade. Indeed, most patients were generally satisfied with their stay, although answers to individual items highlighted significant changes in specific hospital-service quality areas. Despite previous reports on a proven relationship between hospital work environment and patient satisfaction (Aiken et al., 2012), our study failed to show a substantial deterioration in patients’ service quality perceptions over the last decade. A potential explanation for this negative finding may be that overall and subscale patient perception scores lack sensitivity to changes in contrast to specific items. Indeed, combining individual items into a single score may disguise
60 50
49.6 46.3 42.3
44.6
45.9 43.5
45.0 41.3
41.0
41.2
40 Percent
40.4
30 20 10
0
9
20 1
20 0
06 20 07
05
20
04
20
3
20
2
20 0
20 0
01
00
20
20
99
0 19
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In multi-variable analysis, adjusting for age and gender, patient percentage with an overall perception score equal to or higher than eight varied across surveys but without a decreasing linear trend (Figure 1). Indeed, the estimate in 2010 (45 percent) was comparable to that observed in 1999 (46.3 percent), although lower levels were found in the decade’s second half. Patient perception changed in 12/29 individual items between 1999 and 2010 (Appendix). Significant linear trends were observed in patients very or fairly satisfied with three items: an increasing percentage reported that explanations were provided before being examined (item 19) over the study period whereas two items, regarding the physician visiting frequency (item 16) and room comfort (item 21) showed a decreasing linear trend. No significant linear trend was found for the nine remaining items. Interestingly, food perceptions (item 22) demonstrated an abrupt change, with a break-point between 2003 and 2004 (Figure 2).
Study year
Notes: p for heterogeneity=0.001. Percentages were adjusted for age and gender
Figure 1. Patients with an overall perception score equal to or higher than 8.0 by study year
Percent
20
00 01
20
20 20
04 05
20
Study year
03 06
20
Frequency of physician visits
02
20
07
20
09
20
10
20
1 2
0 20
3
0 20
4
0 20 0 20
5
6
0 20
7 0 20
9 0 20
0 1 20
Given explanation before being examined
Study year
0
0 20
10
0
0
20
10
0 20
30
20
9
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
30
9 19
88.5 83.9 85.3 83.8 83.5 86.5 85.1 84.4 85.2 82.3 86.6
99
19
85.3 83.4 81.2 82.7 82.0 81.0 80.6 78.1 80.8 80.0 80.0
Percent
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
Figure 2. Patients very or fairly satisfied with hospital care items by study year Percent
00
20
01
20
02 20
99 19
00 20
01 20
02 20
05 006 2 20
07 20
09 20
10 20
Quality of food
04 05 03 20 20 20 Study year
06 20
07 20
09 20
10 20
61.4 62.5 59.3 63.3 62.1 59.9
Comfort of the room
Study year
03 004 20 2
68.0 67.4 68.7 69.0 69.5
99
19
88.9 86.0 86.8 86.4 85.4 86.5 84.4 83.9 83.2 82.1 83.5
420
Percent
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IJHCQA 27,5
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divergent judgments on different aspects. This hypothesis is supported by previous studies suggesting that the general way in which patient satisfaction is measured may explain its unresponsiveness (Sixma et al., 1998). Interestingly, our instrument pointed out specific care dimensions for which anecdotal evidence of worsening satisfaction existed. Indeed, the declining livingarrangement perceptions was mainly driven by an abrupt change in patients’ food service ratings (item 22) and by a sharp decrease in satisfaction with room comfort (item 21). This observation was consistent with the transition to large scale food production methods and vacuum packaging in 2004 to comply with hospital food service regulations. Although this new production system improved food safety and contained costs, it was also detrimental to sensory characteristics (i.e. appearance, flavor and texture), which commonly cause patient dissatisfaction and complaints (Edwards and Hartwell, 2006). Similarly, the deteriorating trend in patients’ roomcomfort perception likely reflects inconvenience caused by major renovation and large scale refurbishment after tall-building security regulations were enforced. Although patient perception regarding physicians’ technical and interpersonal skill remained unchanged over the study period, two individual items comprising this subscale score showed opposite linear trends. A decreasing percentage were very or fairly satisfied with physician visits (item 16), which may be a negative consequence of medical resident and physician work-hour reductions and increasing time spent on documentation and marginal administrative tasks (Oxentenko et al., 2010). The increasing percentage reporting information provision before being examined supports the hypothesis that care providers paid more attention to patients’ personal needs after the Act on patient-physician relationships (the so-called Kouchner Law) was promulgated in March 2002. Patient expectations regarding public hospital performance may have evolved over the past decade, becoming more realistic in a global pressure on healthcare expenditure context. Hence, lower patient expectations in the late 2000s might explain comparable satisfaction levels over the study period despite hypothetically worsening service quality. Indeed, theoretical patient satisfaction constructs represent variations in perceived discrepancy between an individual’s expectation and actual performance (Hudak et al., 2004; Sitzia and Wood, 1997). It is also possible that periodically reporting patient experience survey results to care providers and managers in our hospital have altered attention paid to patients’ personal needs. This might have counterbalanced the negative consequences of the deteriorating hospital work environment and therefore resulted in rather unchanged perception scores (Boyer et al., 2006). Indeed, patient perception surveys were rated as useful by most care providers and had the potential to make the culture more patient centered (Boyer et al., 2006). Yet this finding contrasts with previous studies that reported little or no improvement in care processes following patient survey programs (Draper et al., 2001; Reeves and Seccombe, 2008; Rozenblum et al., 2013). Hospital quality perceptions should be interpreted in an individual preference and expectation context (Locker and Dunt, 1978). High satisfaction may not be directly related to fulfilled prior expectations but may indicate that patients do not have clear expectations for various hospital aspects. Indeed, modest associations have been reported between clinical quality and patient experience ( Jha et al., 2008). In a previous study, up to 95 percent of the variance in patient satisfaction scores was at the patient level whereas the remaining 5 percent was at the physician level (Sixma et al., 1998). A potential explanation for these findings is that
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patients do not feel competent to evaluate technical skills or are reluctant to express dissatisfaction with clinical care and therefore tend to rely on peripheral hospital-care elements such as comfort, food, visiting hours, accessibility or privacy. Hence, patient experience with hospital-care surveys should complement but not substitute for other care measures. Accordingly, strategies aiming to improve hospital quality, as seen from the patient’s perspective, should be considered with caution (Sixma et al., 1998). Study limitations should be acknowledged. First, we hypothesized that hospital work environment deteriorated following transition to the prospective payment system and after enforcing legislation restricting the working week to 35 hours although it could not be formally proven. Unfortunately, retrospective data on the care providers’ work environment, satisfaction or burn out are not available over the study period. Yet all 13 European and North American countries participating in a multi-center cross-sectional study faced problems with hospital work environment in 2009-2010 (Aiken et al., 2012) and it would be surprising that the situation differed in France. Second, the response rate decreased from 70.2 to 58 percent over the study with the potential for confounding perception scores. Although multi-variable analyses adjusting for changes in respondent demographics were performed, we cannot exclude that unmeasured characteristics may have confounded the results. Third, overall and subscale perception scores sharply increased in 2010 reaching levels comparable to those observed in 1999. Whether this observation reflects a long-term trend or merely short-term fluctuations remains unknown and warrants an extended study period. Fourth, this was a single-center study conducted in a large teaching hospital and the findings may not apply to other facilities. Yet our findings were consistent with patient satisfaction surveys conducted between 2001 and 2010 in Paris and its suburbs’ public hospitals. In 2011, 272 public and private hospitals participated in a national hospital-patient survey on a voluntary basis. Although this survey was repeated in 2012, it will not be possible to examine long-term trends in patients’ quality perceptions. Conclusions This single-center study casts doubt on the purported declining hospital patient quality perceptions over the last decade in France. Despite growing pressure on public hospital expenditure and new working time regulations, only moderate reductions in perception scores were observed after 2005. Overall, patients were satisfied with their hospital stay, although there were specific areas with opportunities for improvement. References Aiken, L.H., Sermeus, W., Van Den Heede, K., Sloane, D.M., Busse, R., Mckee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L. and Kutney-Lee, A. (2012), “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States”, British Medical Journal, Vol. 344, p. e1717. Antoniotti, S., Baumstarck-Barrau, K., Simeoni, M.C., Sapin, C., Labarere, J., Gerbaud, L., Boyer, L., Colin, C., Francois, P. and Auquier, P. (2009), “Validation of a French hospitalized patients’ satisfaction questionnaire: the QSH-45”, International Journal for Quality in Health Care, Vol. 21 No. 4, pp. 243-252.
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Boyer, L., Francois, P., Doutre, E., Weil, G. and Labarere, J. (2006), “Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital”, International Journal for Quality in Health Care, Vol. 18 No. 5, pp. 359-364. Bruster, S., Jarman, B., Bosanquet, N., Weston, D., Erens, R. and Delbanco, T.L. (1994), “National survey of hospital patients”, British Medical Journal, Vol. 309 No. 6968, pp. 1542-1546. Charles, C., Gauld, M., Chambers, L., O’brien, B., Haynes, R.B. and Labelle, R. (1994), “How was your hospital stay? Patients’ reports about their care in Canadian hospitals”, Canadian Medical Association Journal, Vol. 150 No. 11, pp. 1813-1822. Chevreul, K., Durand-Zaleski, I., Bahrami, S.B., Hernandez-Quevedo, C. and Mladovsky, P. (2010), “France: health system review”, Health System Transition, Vol. 12 No. 6, pp. 1-291. Cuzick, J. (1985), “A Wilcoxon-type test for trend”, Statistics in Medicine, Vol. 4 No. 1, pp. 87-90. Degos, L., Romaneix, F., Michel, P. and Bacou, J. (2008), “Can France keep its patients happy?”, British Medical Journal, Vol. 336 No. 7638, pp. 254-257. Dorozynski, A. (2002), “French healthcare system beset by strikes”, British Medical Journal, Vol 324 No. 7332, p. 258. Draper, M., Cohen, P. and Buchan, H. (2001), “Seeking consumer views: what use are results of hospital patient satisfaction surveys?”, International Journal for Quality in Health Care, Vol. 13 No. 6, pp. 463-468. Edwards, J.S. and Hartwell, H.J. (2006), “Hospital food service: a comparative analysis of systems and introducing the ‘Steamplicity’ concept”, Journal of Human Nutrition and Dietetics, Vol. 19 No. 6, pp. 421-430. Elliott, M.N., Lehrman, W.G., Goldstein, E.H., Giordano, L.A., Beckett, M.K., Cohea, C.W. and Cleary, P.D. (2010), “Hospital survey shows improvements in patient experience”, Health Affairs (Millwood), Vol. 29 No. 11, pp. 2061-2067. Fauconnier, J. (2009), “PPS killed me”, Presse Me´dicale, Vol. 38 No. 11, pp. 1560-1561. Fenton, J.J., Jerant, A.F., Bertakis, K.D. and Franks, P. (2012), “The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality”, Archives of Internal Medicine, Vol. 172 No. 5, pp. 405-411. Goldstein, E., Farquhar, M., Crofton, C., Darby, C. and Garfinkel, S. (2005), “Measuring hospital care from the patients’ perspective: an overview of the CAHPS hospital Survey development process”, Health Services Research, Vol. 40 No. 6 P2, pp. 1977-1995. Hudak, P.L., Mckeever, P.D. and Wright, J.G. (2004), “Understanding the meaning of satisfaction with treatment outcome”, Medical Care, Vol. 42 No. 8, pp. 718-725. Isaac, T., Zaslavsky, A.M., Cleary, P.D. and Landon, B.E. (2010), “The relationship between patients’ perception of care and measures of hospital quality and safety”, Health Services Research, Vol. 45 No. 4, pp. 1024-1040. Jenkinson, C., Coulter, A. and Bruster, S. (2002), “The picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries”, International Journal for Quality in Health Care, Vol. 14 No. 5, pp. 353-358. Jha, A.K., Orav, E.J., Zheng, J. and Epstein, A.M. (2008), “Patients’ perception of hospital care in the United States”, New England Journal of Medicine, Vol. 359 No. 18, pp. 1921-1931. Labare`re, J., Fourny, M., Vittoz, J.P., Marin-Pache, S. and Francois, P. (2004), “Refinement and validation of a French in-patient experience questionnaire”, International Journal of Health Care Quality Assurance, Vol. 17 No. 1, pp. 17-25.
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Labare`re, J., Francois, P., Auquier, P., Robert, C. and Fourny, M. (2001), “Development of a French inpatient satisfaction questionnaire”, International Journal for Quality in Health Care, Vol. 13 No. 2, pp. 99-108. Labare`re, J., Francois, P., Bertrand, D., Fourny, M., Olive, F. and Peyrin, J.C. (2000), “Evaluation of inpatient satisfaction. comparison of different survey methods”, Presse Me´dicale, Vol. 29 No. 20, pp. 1112-1114. Locker, D. and Dunt, D. (1978), “Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care”, Social Science and Medicine, Vol. 12 No. 4A, pp. 283-292. Oxentenko, A.S., West, C.P., Popkave, C., Weinberger, S.E. and Kolars, J.C. (2010), “Time spent on clinical documentation: a survey of internal medicine residents and program directors”, Archives of Internal Medicine, Vol. 170 No. 4, pp. 377-380. Reeves, R. and Seccombe, I. (2008), “Do patient surveys work? The influence of a national survey programme on local quality-improvement initiatives”, Quality and Safety in Health Care, Vol. 17 No. 6, pp. 437-441. Rozenblum, R., Lisby, M., Hockey, P.M., Levtzion-Korach, O., Salzberg, C.A., Efrati, N., Lipsitz, S. and Bates, D.W. (2013), “The patient satisfaction chasm: the gap between hospital management and frontline clinicians”, BMJ Quality and Safety, Vol. 22 No. 3, pp. 242-250. Sitzia, J. and Wood, N. (1997), “Patient satisfaction: a review of issues and concepts”, Social Science and Medicine, Vol. 45 No. 12, pp. 1829-1843. Sixma, H.J., Spreeuwenberg, P.M.M. and Van Der Pasch, M.A.A. (1998), “Patient satisfaction with the general practitioner. a two-level analysis”, Medical Care, Vol. 36 No. 2, pp. 212-229. Woodrow, S.I., Segouin, C., Armbruster, J., Hamstra, S.J. and Hodges, B. (2006), “Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education?”, Academic Medicine, Vol. 81 No. 12, pp. 1045-1051. Corresponding author Dr Jose Labarere can be contacted at: [email protected]
I. Nurses’ interpersonal and technical skills nurses 1. Nurses’ availability 2. Nurses’ courtesy 3. Prompt response to call button 4. Pain control 5. Nurses’ technical skills 6. Nurses’ interest in patient’s worries and needs 7. Waiting time following admission II. Information 8. Information about side effects of medications 9. Information about purpose of tests or treatments 10. Communication of test results 11. Provision of information in an understandable way III. Continuity of care 12. Information on recovery process 13. Instructions about medical follow-up 14. Efficiency of the discharge procedure 15. Provision of information to family members IV. Physicians’ interpersonal and technical skills 16. Frequency of physicians’ visits 17. Physicians introduced themselves 18. Physicians’ technical skills 19. Given explanation before being examined
Perceptions items
92.1 96.2 84.3 94.1 96.8 90.8 91.9 77.8 85.1 72.5 83.2 76.2 88.8 92.8 78.7 83.4 76.2 96.3 85.3
77.7 85.6 67.8 83.6 75.7 88.3 90.6 78.5 85.3 78.2 96.4 83.9
2000
89.9 95.1 80.0 91.2 96.7 90.3 90.7
1999
81.2 74.2 96.4 83.8
74.2 90.6 92.7 78.3
76.5 85.3 71.1 84.5
90.0 96.8 81.8 92.5 96.2 90.3 88.7
2001
82.7 75.5 95.6 83.5
74.6 86.5 91.2 78.1
74.8 84.5 70.8 84.5
87.3 95.9 79.1 93.9 96.1 89.9 86.8
2002
82.0 77.7 96.6 86.5
73.4 88.2 91.9 79.5
75.8 86.7 70.9 85.3
90.9 96.1 81.3 93.7 96.2 91.1 88.7
2003
81.0 74.7 95.6 85.2
72.3 87.7 90.2 77.0
74.3 85.7 71.7 82.3
86.9 94.9 78.2 93.7 95.6 89.9 87.3
2004
80.6 77.3 96.2 84.4
74.9 88.2 91.8 76.7
76.5 84.4 70.5 84.8
89.3 95.2 79.2 94.2 96.4 89.6 85.8
2005
78.1 74.7 95.4 85.2
75.5 88.8 91.5 77.8
76.7 86.1 69.3 86.8
87.9 94.9 77.9 92.5 95.5 88.4 87.3
2006
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80.8 74.3 96.1 82.3
73.3 88.8 93.2 75.9
68.7 86.4 70.7 82.1
88.3 95.5 77.8 89.3 93.7 90.3 86.9
2007
80.0 75.5 96.7 86.6
79.6 89.8 91.8 81.0
78.8 88.1 73.6 85.4
89.0 94.6 80.9 93.2 96.7 88.8 87.0
2009
0.004 0.41 0.004 0.003 0.06 0.61 0.001 o0.001 0.43 0.26 0.14 0.08 0.44 0.18 0.48 o0.001a 0.07 0.82 0.03a
90.9 96.3 83.7 91.6 95.8 91.5 89.5 80.5 87.6 73.6 86.3 77.2 87.8 89.8 79.7 80.0 80.2 97.0 88.5
(continued)
p
2010
Appendix
Perception of hospital care quality 425
Table AI. Patients very or fairly satisfied with hospital care (%)
Table AI.
Notes: Items stratified by study year. a p for trend
V. Living arrangements 20. Quietness 21. Comfort of room 22. Quality of food 23. Cleanliness 24. Staff knocked on the door 25. Respect of privacy VI. Convenience 26. Administrative admission process 27. Quality of care provided by x-ray staff 28. Finding one’s way within the hospital building 29. Test coordination and scheduling 82.1 86.4 67.4 92.9 86.1 94.8 93.6 92.5 75.6 89.3
93.2 94.0 75.1 88.3
2000
80.9 86.8 68.0 93.1 79.9 92.9
1999
93.4 92.5 69.7 87.9
81.9 85.4 68.7 92.5 83.1 93.2
2001
94.9 92.8 73.2 88.6
79.9 83.9 69.0 93.2 83.8 92.6
2002
94.9 92.6 72.9 91.4
81.8 88.9 69.5 93.7 85.4 93.5
2003
94.3 94.9 72.9 90.1
80.5 86.0 61.4 90.6 84.6 92.1
2004
94.6 93.5 73.7 89.9
81.6 86.5 62.5 91.0 83.3 93.6
2005
94.1 93.1 72.6 87.7
80.8 84.4 59.3 91.6 85.1 92.9
2006
96.3 89.9 75.2 88.0
80.6 83.2 63.3 91.0 84.7 95.6
2007
93.2 93.8 71.9 87.7
80.3 82.1 62.1 92.2 88.3 91.7
2009
93.7 93.9 74.6 90.5
83.9 83.5 59.9 92.3 89.5 92.3
2010
426
Perceptions items
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0.17 0.04 0.21 0.15
0.73 o0.001a o0.001 0.20 o0.001 0.04
p
IJHCQA 27,5
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IJHCQA 27,5
Trends in patient perception of hospital care quality Pierre Batailler
414 Received 1 February 2013 Revised 19 June 2013 Accepted 25 October 2013
Infection Control Unit, Grenoble University Hospital, Grenoble, France
Patrice Franc¸ois Quality of Care Unit, Grenoble University Hospital, Grenoble, France
Van Moˆ Dang Department of Medicine, Division of Geriatrics, Grenoble University Hospital, Grenoble, France, and
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Elodie Sellier, Jean-Philippe Vittoz, Arnaud Seigneurin and Jose Labarere Quality of Care Unit, Grenoble University Hospital, Grenoble, France Abstract Purpose – The purpose of this paper is to investigate trends in patient hospital quality perceptions between 1999 and 2010. Design/methodology/approach – Original data from 11 cross-sectional surveys carried out in a French single university hospital were analyzed. Based on responses to a 29-item survey instrument, overall and subscale perception scores (range 0-10) were computed covering six key hospital care quality dimensions. Findings – Of 16,516 surveyed patients, 10,704 (64.8 percent) participated in the study. The median overall patient perception score decreased from 7.86 (25th-75th percentiles, 6.67-8.85) in 1999 to 7.82 (25th-75th percentiles, 6.67-8.74) in 2010 ( p for trend o0.001). A decreasing trend was observed for the living arrangement subscale score (from 7.78 in 1999 to 7.50 in 2010, p for trend o0.001). Food service and room comfort perceptions deteriorated over the study period while patients increasingly reported better explanations before being examined. Practical implications – Patient perception scores may disguise divergent judgments on different care aspect while individual items highlight specific areas with room for improvement. Originality/value – Despite growing pressure on healthcare expenditure, this single-center study showed only modest reduction in patients’ hospital-care perceptions in the 2000s. Keywords Patient perception, Public health service Paper type Research paper
International Journal of Health Care Quality Assurance Vol. 27 No. 5, 2014 pp. 414-426 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-02-2013-0014
Introduction Patients’ hospital quality perceptions complement standardized care quality process measures and safety indicators (Fenton et al., 2012; Isaac et al., 2010). Patient satisfaction surveys are used in quality improvement incentive programs and may help consumers make more informed choices when selecting hospitals (Goldstein et al., 2005). Hence, inpatient discharge surveys have been carried out with various purposes ( Jha et al., 2008; Bruster et al., 1994; Charles et al., 1994; Jenkinson et al., 2002; Antoniotti et al., 2009). During the last decade, major healthcare and social reforms involved France’s public hospital staff, including gradual transition to a diagnosis-related group-based prospective payment system in 2004 (Chevreul The authors thank Linda Northrup, English Solutions (Voiron, France), for her assistance in preparing and editing the manuscript.
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et al., 2010) and enforcing legislation restricting the working week to 35 hours for full-time employees in 2002 (Chevreul et al., 2010; Woodrow et al., 2006). Moreover public hospitals faced nursing shortages, low investment, saturated emergency departments and growing discouragement among healthcare teams (Dorozynski, 2002; Fauconnier, 2009). Although 65 percent of French citizens were highly satisfied with their healthcare according to a survey carried out in 2004, some authors questioned whether France’s healthcare providers could keep their patients happy (Degos et al., 2008). To our knowledge, few studies have monitored patients’ hospital quality perception trends during the 2000s (Elliott et al., 2010), so we investigated trends in quality reported by patients discharged from a large public hospital in France between 1999 and 2010. Specifically, we investigate whether patient perception was sensitive to changes in hospital-service quality. Methods Study design We analyzed original data from 11 cross-sectional surveys involving discharged patients from Grenoble University Hospital between 1999 and 2010. Although the survey was carried out annually, it could not be performed in 2008 for logistical reasons. The survey received the French Data Protection Agency’s approval (Commission Nationale de l’Informatique et des Liberte´s, Paris, France). Study site Grenoble University Hospital is a full-teaching hospital with 1,347 acute-care beds serving a predominantly urban population (450,000). It is the regional referral center for the French Northern Alps. Grenoble University Hospital had 58,412 acute-care stays, with a 6.7-day mean length of stay (LoS) in 2010. Staff comprised 1,700 nurses, 420 physicians and 210 medical residents (full time equivalents). Patients Depending on the year, we recruited between 1,480 and 1,520 patients discharged from acute-care during a two-week period in April. Medical, surgical or obstetrics and gynecology inpatients staying more than 24 hours were eligible if they were discharged to their home or to a nursing home. Patients transferred to other acute-care hospitals and those discharged to post-acute-care facilities were not eligible. There was no diagnosis limitation to patient selection. Data collection Information on baseline patient demographics (i.e. age and gender) and hospital stay (i.e. emergency department admission, department type, discharge disposition and LoS) was retrieved from the hospital’s database. Additional patient socio-demographic data including marital status, education level, occupation and patient perceptions were collected using a standardized survey instrument (development and psychometric properties reported in detail elsewhere – Labarere et al., 2000, 2001, 2004). The questionnaire included 29 items covering six key hospital quality dimensions: nurses’ interpersonal and technical skills; information; continuity of care; physicians’ interpersonal and technical skills; convenience; and living arrangements (Appendix). Each item was rated on a four-point Likert scale ranging from strongly disagree (1) to strongly agree (4). The questionnaire was mailed to patients within two to four weeks of discharge along with a prepaid envelope and a cover letter guaranteeing patient
Perception of hospital care quality 415
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416
confidentiality and encouraging them to participate. A follow-up letter was sent to non-respondents two weeks later. Patient perception scores For each patient, we computed six subscales, each corresponding to a key hospital care quality dimension and an overall score, based on his/her 29-item ratings (Labarere et al., 2001, 2004). Each subscale score was computed by summing individual items pertaining to the dimension. Subscale and overall scores were standardized, ranging between 0 and 10, with higher scores denoting a better rating. Subscale scores were coded as missing if more than half the items omitted values. Questionnaires with more than six missing values (i.e. missing values 420 percent) were excluded from the analysis. This is the same strategy used in the instrument’s original development and validation study (Labarere et al., 2001, 2004). Statistical analysis Categorical variables were reported as numbers and percentages and continuous variables as median and 25th and 75th percentiles or mean and standard deviation. Differences in baseline characteristics and patient perception scores were compared using the non-parametric Kruskal-Wallis test for continuous and the w2 test for categorical variables. In uni-variable analysis, temporal trends in overall and subscale perception scores were examined using a non-parametric Wilcoxon-type test for trend (Cuzick, 1985). We assessed the linearity assumption for trends in patient perception scores by checking for improvement in uni-variable model fit after adding fractional polynomial functions. We performed multi-variable logistic regression analysis to examine the independent associations between survey year and the odds of reporting overall perception score equal to or higher than eight. We assessed the log linearity assumption by performing likelihood-ratio tests for nested model specifications. To account for potential confounding; e.g. changes in respondent baseline characteristics, our estimates were adjusted for age and gender. Two-tailed p-values o0.05 were considered statistically significant. All analyses were performed using Stata version 11.0 (Stata Corporation, College Station, TX, USA). Results Of 16,516 patients surveyed, 10,704 (64.8 percent) returned the questionnaire. The response rate decreased from 70.2 percent in 1999 to 58.0 percent in 2010 ( p for linear trend o 0.001). After excluding 688 questionnaires with more than six missing values, the analytical sample was 10,016 respondents. Overall, the respondents’ mean age was 52 years, 5,241 (53.3 percent) were male and 4,143 (41.4 percent) underwent a surgical procedure (Table I). In 2010, respondents were older, were more likely to present to the emergency department and to be hospitalized in medical departments, had shorter stays and were more frequently discharged to home compared to respondents surveyed in 1999 (Table I). The median overall patient perception score was 7.74, with median subscale scores ranging from 7.5 for the information, convenience and physicians’ interpersonal and technical skills dimensions to 8.33 for the continuity dimension (Table II). In the uni-variable analysis, overall patient perception and living arrangements subscale scores decreased between 1999 and 2010 (Table II). No other significant linear trends were found and the linear assumption was rejected for nurses’ interpersonal and technical skills subscale score.
1999
2001
2002
2003
2004
2005
2006
2007
2009
2010
All
311 (33.3)
483 (51.7) 403 (43.1) 49 (5.2) 840 (89.8)
323 (32.7)
504 (51.1) 427 (43.3) 56 (5.7) 860 (87.1)
829 (89.6)
470 (50.8) 408 (44.1) 47 (5.1)
322 (34.8)
797 (89.9)
449 (50.6) 396 (44.6) 42 (4.7)
282 (31.8)
869 (89.3)
482 (49.5) 463 (47.6) 28 (2.9)
334 (34.3)
764 (88.7)
445 (51.7) 386 (44.8) 30 (3.5)
274 (31.8)
373 (42)
345 (42)
0.002 0.20 0.01 0.25
p
779 (89.3) 846 (93.8) 780 (88.4) 755 (92.4) 8,962 (89.5) o0.001
o0.001
3,535 (35.3) o0.001
441 (50.6) 587 (65.1) 551 (62.5) 529 (64.8) 5,447 (54.4) 406 (46.6) 293 (32.5) 296 (33.6) 252 (30.8) 4,143 (41.4) 25 (2.9) 22 (2.4) 35 (4.0) 36 (4.4) 426 (4.3)
281 (32.2) 360 (40)
50.8 (24.3) 51.9 (24.4) 50.9 (24.5) 51.0 (24.4) 51.7 (24.8) 53.9 (24.9) 53.4 (23.9) 54.3 (24.0) 53.6 (23.4) 53.0 (22.1) 52.3 (24.2) 548 (57.0) 483 (53.3) 476 (52.7) 447 (51.9) 518 (54.9) 473 (55.1) 471 (54.6) 467 (52.3) 455 (51.6) 422 (51.7) 5,241 (53.3) 138 (14.3) 123 (13.4) 138 (15.2) 114 (13.1) 128 (13.3) 112 (13.2) 94 (11.1) 143 (16.2) 112 (12.9) 99 (12.3) 1,341 (13.6) 5 (2-10) 5 (3-11) 5 (2-10) 5 (3-10) 5 (2-10) 4 (2-10) 4 (3-9) 5 (2-9) 4 (2-9) 5 (2-9) 5 (2-10)
2000
Notes: n ¼ 10,016. aValues were missing for gender (n ¼ 184) and marital status (n ¼ 179)
Age, mean (SD), year 51.0 (24.5) Male gender, n (%) 481 (50.9) Single, n (%) 140 (14.6) Length of stay, 5 (3-10) median (25th-75th percentiles), d Admission to the 330 (33.9) emergency department, n (%) Department, n (%) Medicine 506 (51.9) Surgery 413 (42.4) Gynecology and 56 (5.7) obstetrics Discharged to 843 (86.5) home, n (%)
Characteristicsa
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Perception of hospital care quality 417
Table I. Respondent characteristics by study year
Table II. Overall and subscale patient perception scores by study year
8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.78 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.89) 7.86 (6.67-8.85)
8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 8.33 (6.67-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.89) 7.98 (6.78-8.85)
2000 (n ¼ 987) 8.33 (7.14-9.33) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (5.83-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.33) 7.78 (6.67-8.74)
2001 (n ¼ 935) 8.10 (6.67-9.33) 7.50 (5.56-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.33) 7.70 (6.44-8.74)
2002 (n ¼ 925)
Notes: aData are given as median (25th-75th percentiles); b p for heterogeneity
Overall
Convenience
Physicians’ interpersonal and technical skills Living arrangements
Continuity of care
Nurses’ interpersonal and technical skills Information
1999 (n ¼ 975) 8.57 (7.14-9.52) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 8.33 (6.67-9.17) 7.78 (6.67-8.89) 7.50 (6.67-8.89) 7.82 (6.67-8.85)
2003 (n ¼ 887) 8.10 (6.67-9.44) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (5.83-9.17) 7.50 (6.11-8.89) 7.50 (6.67-8.33) 7.69 (6.53-8.71)
2004 (n ¼ 973) 8.10 (7.14-9.05) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (6.67-9.17) 7.33 (6.11-8.67) 7.50 (6.67-8.89) 7.70 (6.55-8.69)
2005 (n ¼ 861) 8.10 (6.67-9.05) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (5.83-9.17) 7.33 (6.11-8.67) 7.50 (6.67-8.33) 7.67 (6.44-8.62)
2006 (n ¼ 872) 8.57 (6.67-9.05) 6.67 (5.56-9.17) 7.78 (6.67-9.17) 7.50 (5.83-9.17) 7.22 (6.11-8.89) 7.50 (6.67-8.33) 7.70 (6.55-8.69)
2007 (n ¼ 902)
8.10 (6.67-9.05) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.22 (6.11-8.33) 7.50 (6.67-8.33) 7.70 (6.44-8.62)
2009 (n ¼ 882)
8.33 (7.14-9.44) 7.50 (5.83-9.17) 8.33 (6.67-9.17) 7.50 (6.67-9.17) 7.50 (6.11-8.89) 7.50 (6.67-8.89) 7.82 (6.67-8.74)
2010 (n ¼ 817)
418
Perception score
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8.10 (7.14-9.44) 7.50 (5.83-9.17) 8.33 (6.67-10.00) 7.50 (6.67-9.17) 7.78 (6.11-8.89) 7.50 (6.67-8.33) 7.74 (6.55-8.74)
All (n ¼ 10,016)
o0.001
0.99
o0.001
0.99
0.99
0.99
0.03b
p for trend
IJHCQA 27,5
Perception of hospital care quality 419
Discussion This cross-sectional survey pooled analysis totaling more than 10,000 respondents found little evidence for a decreasing trend in hospital quality perception between 1999 and 2010. After adjusting for changes in baseline respondent characteristics, only modest reductions in overall and subscale perception scores were found in the second half of the 2000s, with estimates in 2010 reaching levels comparable to those observed at the beginning of the decade. Indeed, most patients were generally satisfied with their stay, although answers to individual items highlighted significant changes in specific hospital-service quality areas. Despite previous reports on a proven relationship between hospital work environment and patient satisfaction (Aiken et al., 2012), our study failed to show a substantial deterioration in patients’ service quality perceptions over the last decade. A potential explanation for this negative finding may be that overall and subscale patient perception scores lack sensitivity to changes in contrast to specific items. Indeed, combining individual items into a single score may disguise
60 50
49.6 46.3 42.3
44.6
45.9 43.5
45.0 41.3
41.0
41.2
40 Percent
40.4
30 20 10
0
9
20 1
20 0
06 20 07
05
20
04
20
3
20
2
20 0
20 0
01
00
20
20
99
0 19
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In multi-variable analysis, adjusting for age and gender, patient percentage with an overall perception score equal to or higher than eight varied across surveys but without a decreasing linear trend (Figure 1). Indeed, the estimate in 2010 (45 percent) was comparable to that observed in 1999 (46.3 percent), although lower levels were found in the decade’s second half. Patient perception changed in 12/29 individual items between 1999 and 2010 (Appendix). Significant linear trends were observed in patients very or fairly satisfied with three items: an increasing percentage reported that explanations were provided before being examined (item 19) over the study period whereas two items, regarding the physician visiting frequency (item 16) and room comfort (item 21) showed a decreasing linear trend. No significant linear trend was found for the nine remaining items. Interestingly, food perceptions (item 22) demonstrated an abrupt change, with a break-point between 2003 and 2004 (Figure 2).
Study year
Notes: p for heterogeneity=0.001. Percentages were adjusted for age and gender
Figure 1. Patients with an overall perception score equal to or higher than 8.0 by study year
Percent
20
00 01
20
20 20
04 05
20
Study year
03 06
20
Frequency of physician visits
02
20
07
20
09
20
10
20
1 2
0 20
3
0 20
4
0 20 0 20
5
6
0 20
7 0 20
9 0 20
0 1 20
Given explanation before being examined
Study year
0
0 20
10
0
0
20
10
0 20
30
20
9
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
30
9 19
88.5 83.9 85.3 83.8 83.5 86.5 85.1 84.4 85.2 82.3 86.6
99
19
85.3 83.4 81.2 82.7 82.0 81.0 80.6 78.1 80.8 80.0 80.0
Percent
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
Figure 2. Patients very or fairly satisfied with hospital care items by study year Percent
00
20
01
20
02 20
99 19
00 20
01 20
02 20
05 006 2 20
07 20
09 20
10 20
Quality of food
04 05 03 20 20 20 Study year
06 20
07 20
09 20
10 20
61.4 62.5 59.3 63.3 62.1 59.9
Comfort of the room
Study year
03 004 20 2
68.0 67.4 68.7 69.0 69.5
99
19
88.9 86.0 86.8 86.4 85.4 86.5 84.4 83.9 83.2 82.1 83.5
420
Percent
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IJHCQA 27,5
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divergent judgments on different aspects. This hypothesis is supported by previous studies suggesting that the general way in which patient satisfaction is measured may explain its unresponsiveness (Sixma et al., 1998). Interestingly, our instrument pointed out specific care dimensions for which anecdotal evidence of worsening satisfaction existed. Indeed, the declining livingarrangement perceptions was mainly driven by an abrupt change in patients’ food service ratings (item 22) and by a sharp decrease in satisfaction with room comfort (item 21). This observation was consistent with the transition to large scale food production methods and vacuum packaging in 2004 to comply with hospital food service regulations. Although this new production system improved food safety and contained costs, it was also detrimental to sensory characteristics (i.e. appearance, flavor and texture), which commonly cause patient dissatisfaction and complaints (Edwards and Hartwell, 2006). Similarly, the deteriorating trend in patients’ roomcomfort perception likely reflects inconvenience caused by major renovation and large scale refurbishment after tall-building security regulations were enforced. Although patient perception regarding physicians’ technical and interpersonal skill remained unchanged over the study period, two individual items comprising this subscale score showed opposite linear trends. A decreasing percentage were very or fairly satisfied with physician visits (item 16), which may be a negative consequence of medical resident and physician work-hour reductions and increasing time spent on documentation and marginal administrative tasks (Oxentenko et al., 2010). The increasing percentage reporting information provision before being examined supports the hypothesis that care providers paid more attention to patients’ personal needs after the Act on patient-physician relationships (the so-called Kouchner Law) was promulgated in March 2002. Patient expectations regarding public hospital performance may have evolved over the past decade, becoming more realistic in a global pressure on healthcare expenditure context. Hence, lower patient expectations in the late 2000s might explain comparable satisfaction levels over the study period despite hypothetically worsening service quality. Indeed, theoretical patient satisfaction constructs represent variations in perceived discrepancy between an individual’s expectation and actual performance (Hudak et al., 2004; Sitzia and Wood, 1997). It is also possible that periodically reporting patient experience survey results to care providers and managers in our hospital have altered attention paid to patients’ personal needs. This might have counterbalanced the negative consequences of the deteriorating hospital work environment and therefore resulted in rather unchanged perception scores (Boyer et al., 2006). Indeed, patient perception surveys were rated as useful by most care providers and had the potential to make the culture more patient centered (Boyer et al., 2006). Yet this finding contrasts with previous studies that reported little or no improvement in care processes following patient survey programs (Draper et al., 2001; Reeves and Seccombe, 2008; Rozenblum et al., 2013). Hospital quality perceptions should be interpreted in an individual preference and expectation context (Locker and Dunt, 1978). High satisfaction may not be directly related to fulfilled prior expectations but may indicate that patients do not have clear expectations for various hospital aspects. Indeed, modest associations have been reported between clinical quality and patient experience ( Jha et al., 2008). In a previous study, up to 95 percent of the variance in patient satisfaction scores was at the patient level whereas the remaining 5 percent was at the physician level (Sixma et al., 1998). A potential explanation for these findings is that
Perception of hospital care quality 421
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422
patients do not feel competent to evaluate technical skills or are reluctant to express dissatisfaction with clinical care and therefore tend to rely on peripheral hospital-care elements such as comfort, food, visiting hours, accessibility or privacy. Hence, patient experience with hospital-care surveys should complement but not substitute for other care measures. Accordingly, strategies aiming to improve hospital quality, as seen from the patient’s perspective, should be considered with caution (Sixma et al., 1998). Study limitations should be acknowledged. First, we hypothesized that hospital work environment deteriorated following transition to the prospective payment system and after enforcing legislation restricting the working week to 35 hours although it could not be formally proven. Unfortunately, retrospective data on the care providers’ work environment, satisfaction or burn out are not available over the study period. Yet all 13 European and North American countries participating in a multi-center cross-sectional study faced problems with hospital work environment in 2009-2010 (Aiken et al., 2012) and it would be surprising that the situation differed in France. Second, the response rate decreased from 70.2 to 58 percent over the study with the potential for confounding perception scores. Although multi-variable analyses adjusting for changes in respondent demographics were performed, we cannot exclude that unmeasured characteristics may have confounded the results. Third, overall and subscale perception scores sharply increased in 2010 reaching levels comparable to those observed in 1999. Whether this observation reflects a long-term trend or merely short-term fluctuations remains unknown and warrants an extended study period. Fourth, this was a single-center study conducted in a large teaching hospital and the findings may not apply to other facilities. Yet our findings were consistent with patient satisfaction surveys conducted between 2001 and 2010 in Paris and its suburbs’ public hospitals. In 2011, 272 public and private hospitals participated in a national hospital-patient survey on a voluntary basis. Although this survey was repeated in 2012, it will not be possible to examine long-term trends in patients’ quality perceptions. Conclusions This single-center study casts doubt on the purported declining hospital patient quality perceptions over the last decade in France. Despite growing pressure on public hospital expenditure and new working time regulations, only moderate reductions in perception scores were observed after 2005. Overall, patients were satisfied with their hospital stay, although there were specific areas with opportunities for improvement. References Aiken, L.H., Sermeus, W., Van Den Heede, K., Sloane, D.M., Busse, R., Mckee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L. and Kutney-Lee, A. (2012), “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States”, British Medical Journal, Vol. 344, p. e1717. Antoniotti, S., Baumstarck-Barrau, K., Simeoni, M.C., Sapin, C., Labarere, J., Gerbaud, L., Boyer, L., Colin, C., Francois, P. and Auquier, P. (2009), “Validation of a French hospitalized patients’ satisfaction questionnaire: the QSH-45”, International Journal for Quality in Health Care, Vol. 21 No. 4, pp. 243-252.
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Boyer, L., Francois, P., Doutre, E., Weil, G. and Labarere, J. (2006), “Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital”, International Journal for Quality in Health Care, Vol. 18 No. 5, pp. 359-364. Bruster, S., Jarman, B., Bosanquet, N., Weston, D., Erens, R. and Delbanco, T.L. (1994), “National survey of hospital patients”, British Medical Journal, Vol. 309 No. 6968, pp. 1542-1546. Charles, C., Gauld, M., Chambers, L., O’brien, B., Haynes, R.B. and Labelle, R. (1994), “How was your hospital stay? Patients’ reports about their care in Canadian hospitals”, Canadian Medical Association Journal, Vol. 150 No. 11, pp. 1813-1822. Chevreul, K., Durand-Zaleski, I., Bahrami, S.B., Hernandez-Quevedo, C. and Mladovsky, P. (2010), “France: health system review”, Health System Transition, Vol. 12 No. 6, pp. 1-291. Cuzick, J. (1985), “A Wilcoxon-type test for trend”, Statistics in Medicine, Vol. 4 No. 1, pp. 87-90. Degos, L., Romaneix, F., Michel, P. and Bacou, J. (2008), “Can France keep its patients happy?”, British Medical Journal, Vol. 336 No. 7638, pp. 254-257. Dorozynski, A. (2002), “French healthcare system beset by strikes”, British Medical Journal, Vol 324 No. 7332, p. 258. Draper, M., Cohen, P. and Buchan, H. (2001), “Seeking consumer views: what use are results of hospital patient satisfaction surveys?”, International Journal for Quality in Health Care, Vol. 13 No. 6, pp. 463-468. Edwards, J.S. and Hartwell, H.J. (2006), “Hospital food service: a comparative analysis of systems and introducing the ‘Steamplicity’ concept”, Journal of Human Nutrition and Dietetics, Vol. 19 No. 6, pp. 421-430. Elliott, M.N., Lehrman, W.G., Goldstein, E.H., Giordano, L.A., Beckett, M.K., Cohea, C.W. and Cleary, P.D. (2010), “Hospital survey shows improvements in patient experience”, Health Affairs (Millwood), Vol. 29 No. 11, pp. 2061-2067. Fauconnier, J. (2009), “PPS killed me”, Presse Me´dicale, Vol. 38 No. 11, pp. 1560-1561. Fenton, J.J., Jerant, A.F., Bertakis, K.D. and Franks, P. (2012), “The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality”, Archives of Internal Medicine, Vol. 172 No. 5, pp. 405-411. Goldstein, E., Farquhar, M., Crofton, C., Darby, C. and Garfinkel, S. (2005), “Measuring hospital care from the patients’ perspective: an overview of the CAHPS hospital Survey development process”, Health Services Research, Vol. 40 No. 6 P2, pp. 1977-1995. Hudak, P.L., Mckeever, P.D. and Wright, J.G. (2004), “Understanding the meaning of satisfaction with treatment outcome”, Medical Care, Vol. 42 No. 8, pp. 718-725. Isaac, T., Zaslavsky, A.M., Cleary, P.D. and Landon, B.E. (2010), “The relationship between patients’ perception of care and measures of hospital quality and safety”, Health Services Research, Vol. 45 No. 4, pp. 1024-1040. Jenkinson, C., Coulter, A. and Bruster, S. (2002), “The picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries”, International Journal for Quality in Health Care, Vol. 14 No. 5, pp. 353-358. Jha, A.K., Orav, E.J., Zheng, J. and Epstein, A.M. (2008), “Patients’ perception of hospital care in the United States”, New England Journal of Medicine, Vol. 359 No. 18, pp. 1921-1931. Labare`re, J., Fourny, M., Vittoz, J.P., Marin-Pache, S. and Francois, P. (2004), “Refinement and validation of a French in-patient experience questionnaire”, International Journal of Health Care Quality Assurance, Vol. 17 No. 1, pp. 17-25.
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Labare`re, J., Francois, P., Auquier, P., Robert, C. and Fourny, M. (2001), “Development of a French inpatient satisfaction questionnaire”, International Journal for Quality in Health Care, Vol. 13 No. 2, pp. 99-108. Labare`re, J., Francois, P., Bertrand, D., Fourny, M., Olive, F. and Peyrin, J.C. (2000), “Evaluation of inpatient satisfaction. comparison of different survey methods”, Presse Me´dicale, Vol. 29 No. 20, pp. 1112-1114. Locker, D. and Dunt, D. (1978), “Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care”, Social Science and Medicine, Vol. 12 No. 4A, pp. 283-292. Oxentenko, A.S., West, C.P., Popkave, C., Weinberger, S.E. and Kolars, J.C. (2010), “Time spent on clinical documentation: a survey of internal medicine residents and program directors”, Archives of Internal Medicine, Vol. 170 No. 4, pp. 377-380. Reeves, R. and Seccombe, I. (2008), “Do patient surveys work? The influence of a national survey programme on local quality-improvement initiatives”, Quality and Safety in Health Care, Vol. 17 No. 6, pp. 437-441. Rozenblum, R., Lisby, M., Hockey, P.M., Levtzion-Korach, O., Salzberg, C.A., Efrati, N., Lipsitz, S. and Bates, D.W. (2013), “The patient satisfaction chasm: the gap between hospital management and frontline clinicians”, BMJ Quality and Safety, Vol. 22 No. 3, pp. 242-250. Sitzia, J. and Wood, N. (1997), “Patient satisfaction: a review of issues and concepts”, Social Science and Medicine, Vol. 45 No. 12, pp. 1829-1843. Sixma, H.J., Spreeuwenberg, P.M.M. and Van Der Pasch, M.A.A. (1998), “Patient satisfaction with the general practitioner. a two-level analysis”, Medical Care, Vol. 36 No. 2, pp. 212-229. Woodrow, S.I., Segouin, C., Armbruster, J., Hamstra, S.J. and Hodges, B. (2006), “Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education?”, Academic Medicine, Vol. 81 No. 12, pp. 1045-1051. Corresponding author Dr Jose Labarere can be contacted at: [email protected]
I. Nurses’ interpersonal and technical skills nurses 1. Nurses’ availability 2. Nurses’ courtesy 3. Prompt response to call button 4. Pain control 5. Nurses’ technical skills 6. Nurses’ interest in patient’s worries and needs 7. Waiting time following admission II. Information 8. Information about side effects of medications 9. Information about purpose of tests or treatments 10. Communication of test results 11. Provision of information in an understandable way III. Continuity of care 12. Information on recovery process 13. Instructions about medical follow-up 14. Efficiency of the discharge procedure 15. Provision of information to family members IV. Physicians’ interpersonal and technical skills 16. Frequency of physicians’ visits 17. Physicians introduced themselves 18. Physicians’ technical skills 19. Given explanation before being examined
Perceptions items
92.1 96.2 84.3 94.1 96.8 90.8 91.9 77.8 85.1 72.5 83.2 76.2 88.8 92.8 78.7 83.4 76.2 96.3 85.3
77.7 85.6 67.8 83.6 75.7 88.3 90.6 78.5 85.3 78.2 96.4 83.9
2000
89.9 95.1 80.0 91.2 96.7 90.3 90.7
1999
81.2 74.2 96.4 83.8
74.2 90.6 92.7 78.3
76.5 85.3 71.1 84.5
90.0 96.8 81.8 92.5 96.2 90.3 88.7
2001
82.7 75.5 95.6 83.5
74.6 86.5 91.2 78.1
74.8 84.5 70.8 84.5
87.3 95.9 79.1 93.9 96.1 89.9 86.8
2002
82.0 77.7 96.6 86.5
73.4 88.2 91.9 79.5
75.8 86.7 70.9 85.3
90.9 96.1 81.3 93.7 96.2 91.1 88.7
2003
81.0 74.7 95.6 85.2
72.3 87.7 90.2 77.0
74.3 85.7 71.7 82.3
86.9 94.9 78.2 93.7 95.6 89.9 87.3
2004
80.6 77.3 96.2 84.4
74.9 88.2 91.8 76.7
76.5 84.4 70.5 84.8
89.3 95.2 79.2 94.2 96.4 89.6 85.8
2005
78.1 74.7 95.4 85.2
75.5 88.8 91.5 77.8
76.7 86.1 69.3 86.8
87.9 94.9 77.9 92.5 95.5 88.4 87.3
2006
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80.8 74.3 96.1 82.3
73.3 88.8 93.2 75.9
68.7 86.4 70.7 82.1
88.3 95.5 77.8 89.3 93.7 90.3 86.9
2007
80.0 75.5 96.7 86.6
79.6 89.8 91.8 81.0
78.8 88.1 73.6 85.4
89.0 94.6 80.9 93.2 96.7 88.8 87.0
2009
0.004 0.41 0.004 0.003 0.06 0.61 0.001 o0.001 0.43 0.26 0.14 0.08 0.44 0.18 0.48 o0.001a 0.07 0.82 0.03a
90.9 96.3 83.7 91.6 95.8 91.5 89.5 80.5 87.6 73.6 86.3 77.2 87.8 89.8 79.7 80.0 80.2 97.0 88.5
(continued)
p
2010
Appendix
Perception of hospital care quality 425
Table AI. Patients very or fairly satisfied with hospital care (%)
Table AI.
Notes: Items stratified by study year. a p for trend
V. Living arrangements 20. Quietness 21. Comfort of room 22. Quality of food 23. Cleanliness 24. Staff knocked on the door 25. Respect of privacy VI. Convenience 26. Administrative admission process 27. Quality of care provided by x-ray staff 28. Finding one’s way within the hospital building 29. Test coordination and scheduling 82.1 86.4 67.4 92.9 86.1 94.8 93.6 92.5 75.6 89.3
93.2 94.0 75.1 88.3
2000
80.9 86.8 68.0 93.1 79.9 92.9
1999
93.4 92.5 69.7 87.9
81.9 85.4 68.7 92.5 83.1 93.2
2001
94.9 92.8 73.2 88.6
79.9 83.9 69.0 93.2 83.8 92.6
2002
94.9 92.6 72.9 91.4
81.8 88.9 69.5 93.7 85.4 93.5
2003
94.3 94.9 72.9 90.1
80.5 86.0 61.4 90.6 84.6 92.1
2004
94.6 93.5 73.7 89.9
81.6 86.5 62.5 91.0 83.3 93.6
2005
94.1 93.1 72.6 87.7
80.8 84.4 59.3 91.6 85.1 92.9
2006
96.3 89.9 75.2 88.0
80.6 83.2 63.3 91.0 84.7 95.6
2007
93.2 93.8 71.9 87.7
80.3 82.1 62.1 92.2 88.3 91.7
2009
93.7 93.9 74.6 90.5
83.9 83.5 59.9 92.3 89.5 92.3
2010
426
Perceptions items
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0.17 0.04 0.21 0.15
0.73 o0.001a o0.001 0.20 o0.001 0.04
p
IJHCQA 27,5
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