The Effect of Hospital Size and Teaching Status on Patient Experiences With Hospital Care

Factors influencing patient experience in hospital wards: a systematic review

BACKGROUND

Patient experience plays an essential role in improving clinical effectiveness and patient safety. It's important to identify factors influencing patient experience and to improve quality of healthcare.

OBJECTIVE

To identify factors that influence patient experience in hospital wards.

METHODS

We conducted a systematic review including six databases; they were PubMed, CINAHL, Embase, PsycInfo, ProQuest, and Cochrane. Studies were included if they met the inclusion criteria. The JBI checklist was used to perform quality appraisal. We used 5 domains of the ecological model to organize and synthesize our findings to comprehensively understand the multi-level factors influencing the issue.

RESULT

A total of 138 studies were included, and 164 factors were identified. These factors were integrated into 6 domains. All domains but one (survey-related factors) could be mapped onto the attributes of the ecological framework: intrapersonal, interpersonal, institutional, community, and public policy level factors. All factors had mixed effect on patient experience. The intrapersonal level refers to individual characteristics of patients. The interpersonal level refers to interactions between patients and healthcare providers, such as the caring time spent by a nurse. The institutional level refers to organizational characteristics, rules and regulations for operations, such as hospital size and accreditation. The community level refers to relationships among organizations, institutions, and informational networks within defined boundaries, such as a hospital located in a larger population area. Public policy level refers to local, state, national, and global laws and policies, including health insurance policies. The sixth domain, survey-related factors, was added to the framework and included factors such as survey response rate and survey response time.

CONCLUSION

The factors influencing patient experience are comprehensive, ranging from intrapersonal to public policy. Providers should adopt a holistic and integrated perspective to assess patient experience and develop context-specific interventions to improve the quality of care. PROSPERO REGISTRATION NUMBER CRD42023401066.

Validating perceptions with clinical measures: A latent growth curve on the associations between patient experience and hospital-associated infections in Norway over time

OBJECTIVE

The aim of the study was to examine the parallel relationships between the growth rates of patient-reported experiences and hospital-associated infections (HAIs) over time.

DATA SOURCES/STUDY SETTING

The study employed five waves (years) of data among hospitals across Norway from the Norwegian Health Directorate website for both patient experience and HAIs.

STUDY DESIGN

The study employed a longitudinal design, testing and comparing different models. A latent growth curve model with autoregressions emerged as the best fit for the data.

DATA COLLECTION/EXTRACTION METHODS

The data extracted from the website included 102 hospitals. However, the study used 61 hospitals after data cleaning, each with 400 patient respondents for each year.

PRINCIPAL FINDINGS

The results showed that for both patient experiences and HAIs, hospitals that recorded higher scores at the starting point experienced a lower growth rate over time compared to hospitals that recorded lower infections at the starting point. Second, it was found that the starting point for patient experience significantly related to the starting point for HAIs, such that the higher the score for patient experience, the lower the score on infections across hospitals. The results also indicated that almost all lagged effects on either patient-reported experience or HAIs were significant.

CONCLUSIONS

This study shows the significance of patient experience, not only for patient-reported outcomes but also for clinical outcomes. This thus ascertains the relevance of the patient experience pillar for the other pillars of quality health care, namely, clinical effectiveness and safety.

Google star ratings of Canadian hospitals: a nationwide cross-sectional analysis

BACKGROUND

Data on patients' self-reported hospital experience can help guide quality improvement. Traditional patient survey programmes are resource intensive, and results are not always publicly accessible. Unsolicited online hospital reviews are an alternative data source; however, the nature of online reviews for Canadian hospitals is unknown.

METHODS

We conducted a nationwide cross-sectional study of Canadian acute care hospitals with more than 10 Google Reviews during the 2018-2019 fiscal year. We characterised the volume and distribution of Google Reviews of Canadian hospitals, and assessed their correlation with hospital characteristics (teaching status, size, occupancy rate, length of stay, resource utilisation) and Canadian Patient Experience Survey on Inpatient Care (CPES-IC) scores.

RESULTS

167 out of 523 (31.9%) acute care hospitals in Canada met the inclusion criteria. Among included hospitals, there was a total of 10 395 Google Reviews and a median of 35 reviews per hospital. The mean Google Star Rating for included hospitals was 2.85 out of 5, with a range of 1.36-4.57. Teaching hospitals had significantly higher mean Google Star Ratings compared with non-teaching hospitals (3.16 vs 2.81, p <0.01). There was a weak, positive correlation between hospitals' Google Star Ratings and CPES-IC 'Overall Hospital Experience' scores (p =0.04), but no significant correlation between Google Star Ratings and other hospital characteristics or subcategories of CPES-IC scores.

INTERPRETATION

There is significant interhospital variation in patients' self-reported care experiences at Canadian acute care hospitals. Online reviews can serve as a readily accessible source of real-time data for hospitals to monitor and improve the patient experience.

Perceived Barriers to Patient Mobilization Among Therapy and Nursing Acute Care Staff: A Multi-Site Survey Study

OBJECTIVE

To identify differences in perceived barriers to patient mobilization in acute care among therapy and nursing clinicians, and among hospitals of different sizes and types.

DESIGN

Cross-sectional survey study.

SETTING

Eight hospitals of various sizes and types (teaching vs non-teaching; urban vs rural), from 2 different states in the Western region of the United States.

PARTICIPANTS

A nonprobability sample of 568 acute care clinicians (N=586) involved in direct patient care were surveyed. Clinicians indicated a clinical role within the branch of therapy (physical therapy or occupational therapy) or nursing (registered nurse or nurse assistant).

MAIN OUTCOME MEASURES

The Patient Mobilization Attitudes and Beliefs Survey (PMABS) was used to assess perceived barriers to early patient mobilization among therapy and nursing staff. A PMABS total score and 3 subscale scores (knowledge, attitudes, or behaviors associated with barriers to mobilization) were calculated, with higher scores indicative of greater mobilization barriers.

RESULTS

Mean PMABS total scores were significantly lower (better) for therapy providers (24.63±6.67) than nursing providers (38.12±10.95), P<.001. Additionally, therapy providers had significantly lower scores than nursing providers on all 3 subscales (all P<.001). Item-specific analyses revealed significant differences in responses between therapy and nursing staff on 22 of 25 items, with nursing staff indicating greater perceptions of barriers than therapy staff on 20 of the 22 items. The top 5 items with the largest response differences between therapy and nursing clinicians included adequate time to mobilize patients, understanding appropriate referral to therapy staff, knowledge on when it is safe to mobilize patients, confidence in the ability to mobilize patients, and receiving training on methods of safe mobilization. While hospital type did not affect perceived barriers to early mobilization, PMABS scores were significantly higher for large and small hospitals when compared to medium-sized hospitals.

CONCLUSION

Perceived barriers to patient mobilization exist among therapy and nursing acute care clinicians, with greater barriers noted among nursing staff for knowledge, attitudes, and behaviors associated with patient mobility practices. Findings suggest future work is warranted, with opportunities for therapy providers to collaborate with nursing providers to address barriers to implementing patient mobility.

The drivers of the digital transformation in the healthcare industry: An empirical analysis in Italian hospitals

In recent years, driven by the spread of the COVID-19 pandemic, digital transformation in the healthcare sector is becoming increasingly important. Digital healthcare technologies, if adopted in a targeted manner and implemented in a cost-effective way, make it possible to reduce healthcare inequalities, improve the quality of healthcare provided and increase the well-being of citizens. The importance of digital transformation in healthcare is also attracting interest from academics. However, at present, there are few studies aimed at examining the degree of digital transformation in healthcare and the drivers of the adoption and implementation of digital solutions by healthcare facilities. This study aims to fill this gap by analysing the level of digital transformation of Italian hospitals and the factors that can affect this level of digital transformation. The analysis, conducted on a sample of 103 hospitals, shows a positive and significant impact of the hospital size, hospital age and hospital teaching status on the level of digital transformation. Furthermore, in relation to hospital complexity, it shows a positive effect of the presence of the emergency room and a non-significant influence of the number of hospital departments on the level of digital transformation.

Elements of patient satisfaction: An integrative review

AIM

To summarize the scientific literature on the elements essential to understanding a nursing definition of patient satisfaction.

DESIGN

Whittemore and Knafl's methodology was used for this integrative review.

METHODS

Articles were included if the studies they explored patient satisfaction in patient populations and measured patient satisfaction using standardized, validated instruments. Elements in this review were defined as the essential components that create the complex concept of patient satisfaction.

RESULTS

Thirty articles were found and analysed in full. Five definitions of patient satisfaction were used, all of which were at least 20 years old. Twenty-two different measures of patient satisfaction were used, six of which were nursing-specific. Sixty-eight elements of patient satisfaction were studied in the included articles. Forty-three elements were reported as having a significant relationship with patient satisfaction, 25 were reported as having no significant relationship. Eight elements had both significant and non-significant relationships.

The Different Classification of Hospitals Impact on Medical Outcomes of Patients in China

Background

In China, different classification of hospitals (COH) provide treatment for patients with different degrees of illness. COH play an important role in Chinese medical outcomes, but there is a lack of quantitative description of how much impact the results have. The objective of this study is to examine the correlation between COH on medical outcomes with the hope of providing insights into appropriate care and resource allocation.

Methods

From the perspective of the COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with a sample size of 512,658 hospitalized patients, this study used the nested multinomial logit model (NMNL) to estimate the impact of COH on the medical outcomes.

Results

The patients were mainly elderly, with an average age of 66.28 years old. The average length of stay was 9.61 days. The female and male gender were split evenly. A high level of hospitals is positively and significantly associated with the death and transfer rates (p < 0.001), which may be related to more severe illness among patients in high COH.

Conclusion

The COH made a difference in the medical outcomes significantly. COH should be reasonably selected according to disease types to achieve the optimal medical outcome. So, China should promote the construction of a tiered delivery system.

Nurses' Perspectives on Inpatient Care Responsiveness at the Gazan Public Hospitals

Background

Responsiveness is one of the intrinsic goals of health systems. This study aimed at assessing the responsiveness of inpatient care in accordance to nurses' perspectives, particularly in internal medicine ‘medical’ and surgical departments, at the Gazan public general hospitals in 2020.

Methods

This cross-sectional descriptive study was conducted at 5 public general hospitals in Gaza. Data were collected from 277 nurses using an interview-based questionnaire composed mainly of 36 items to measure responsiveness on a 4-point Likert scale. Descriptive statistics, independent t-test and analysis of variance (ANOVA) using SPSS 22.0.

Results

The overall responsiveness was about 77.5%. Access to social support was the highest-performing domain but it was the less important. Dignity was the second-highest in performance but the most important domain. Choice of provider and quality of basic amenities were almost the lowest in both performance and importance. Hospital, marital status, educational level, position at work, income, department, and the experience in the current ward have led to significant differences in the level of responsiveness.

Conclusion

Supply-side should be considered to delineate the status quo of responsiveness accurately. There is a room for further improvement in the interpersonal domains of responsiveness without extravagant expenditures. Policymakers need to emphasize on better allocation of budget for client-orientation domains of responsiveness as well. Hospital characteristics had a pivotal role in creating significant differences among respondents. Likewise, socioeconomic status and cultural diversity of nurses led to significant variations in their responses, hence, this calls for robust and well-designed researches, including non-public hospitals, to determine the most influential factors.

A nationwide participatory programme to measure person-centred hospital care in Italy: Results and implications for continuous improvement

Background

Patient‐centredness has been targeted by the Italian government as a key theme for the future development of health services.

Objective

Measuring patient‐centred health services in partnership with citizens, health professionals and decision makers.

Design

National participatory survey in a large test set of hospitals at national level.

Setting and participants

A total of 387 hospital visits conducted in 16 Italian regions by over 1,500 citizens and health professionals during 2017‐2018.

Main variables and outcome measures

An ad hoc checklist was used to assess person‐centredness in hospital care through 243 items, grouped in 4 main areas, 12 sub‐areas and 29 person‐centred criteria (scored 0‐10). GEE linear multivariate regression was used to explore the relation between hospital characteristics and person‐centredness.

Results

Person‐centred scores were moderately high, with substantial variation overall (median score: 7.0, range: 3.2‐9.5) and by area (Care Processes: 6.8, 2.0‐9.8; Access: 7.4, 2.7‐9.7; Transparency: 6.7, 3.4‐9.5 and Relationship: 7.3, 0.8‐10.0). Multivariate regression found higher scores for increasing volumes of activity (quartile increase: +0.21; 95% CI: 0.13, 0.29) and lower scores in the south and islands (−1.03; −1.62,‐0.45).

Discussion

The checklist has been applied successfully by over 1,500 collaborators who assessed hospitals in 16 distinct Regions and Autonomous Provinces of Italy. Despite an overall positive mark, all scores were highly variable by location and hospital characteristics.

Conclusion and patient or public contribution

A national participatory programme to improve patient‐centredness in Italian hospitals highlighted critical areas with the direct input of citizens.

A comparative study of patients' satisfaction with different levels of hospitals in Beijing: why do patients prefer high-level hospitals?

Background

To promote the integration of medical resources, Beijing has built medical alliances since 2012, but this reform has not changed the state of disordered medical treatment. Patients are still willing to go to high-level hospitals for medical treatment. What causes patients to prefer high-level hospitals? To explore the reasons behind this preference for high-level medical treatment among patients and to guide patients to make visits in an orderly manner, we conducted this study and compared patients’ satisfaction with hospitals of different levels in the context of medical resource integration.

Methods

This study conducted a questionnaire survey among 1250 patients who were selected in 18 medical alliances in Beijing from October to December 2016. The study type is a comparative study based on cross-sectional data. Patient satisfaction was the main outcome, and descriptive analysis, chi-square tests, nonparametric tests and binary logistic regression analysis were used. The level of statistical significance was set at p < 0.05.

Results

The overall satisfaction score of the medical alliances was 3.375, and the satisfaction scores of core hospitals and cooperative hospitals were 2.77 and 3.07, respectively. The overall patient satisfaction rate was 44.62%, and the satisfaction rates of core hospitals and cooperative hospitals were 34.34 and 50.43%, respectively. The type of hospital and understanding of medical alliance policy were the factors associated with patient satisfaction with the medical alliance.

Conclusions

The patients’ satisfaction with cooperative hospitals was higher than their satisfaction with core hospitals. Although the patients were more satisfied with the service attitude of the cooperative hospitals, they still preferred core hospitals due to their higher expectations for their medical treatment and greater trust in their medical technology. It is necessary to explore the establishment of closed medical alliances under the unified management of human and financial resources to enable medical alliances to become a community of common interests and provide integrated medical services for patients.

Patient-experience during delivery in public health facilities in Uttar Pradesh, India

In India, most women now delivery in hospitals or other facilities, however, maternal and neonatal mortality remains stubbornly high. Studies have shown that mistreatment causes delays in care-seeking, early discharge and poor adherence to post-delivery guidance. This study seeks to understand the variation of women’s experiences in different levels of government facilities. This information can help to guide improvement planning. We surveyed 2018 women who gave birth in a representative set of 40 government facilities from across Uttar Pradesh (UP) state in northern India. Women were asked about their experiences of care, using an established scale for person-centred care. We asked questions specific to treatment and clinical care, including whether tests such as blood pressure, contraction timing, newborn heartbeat or vaginal exams were conducted, and whether medical assessments for mothers or newborns were done prior to discharge. Women delivering in hospitals reported less attentive care than women in lower-level facilities, and were less trusting of their providers. After controlling for a range of demographic attributes, we found that better access, higher clinical quality, and lower facility-level, were all significantly predictive of patient-centred care. In UP, lower-level facilities are more accessible, women have greater trust for the providers and women report being better treated than in hospitals. For the vast majority of women who will have a safe and uncomplicated delivery, our findings suggest that the best option would be to invest in improvements mid-level facilities, with access to effective and efficient emergency referral and transportation systems should they be needed.

Does facility type and location impact upon patient experiences in emergency departments? Secondary analysis of a state-wide, cross-sectional survey

OBJECTIVE

To identify the extent to which patient experiences in the ED differ depending on facility type (based on bed numbers, services available and annual separations), and location (level of remoteness).

METHODS

Data from a 2015 state-wide (Queensland, Australia) public ED patient experience survey were linked to sociodemographic and presentation-related characteristics data. Survey items were individually scored (from 0 to 100), and averaged across 13 pre-determined patient experience topic areas. Descriptive statistics were used to report on patient sociodemographic and presentation-related characteristics. One-way analysis of variance tests were used to identify associations between patient-reported experience scores, facility types and location.

RESULTS

A total of 10 553 patients over the age of 16 years completed the survey. All patients reported scores above 75 for 7 of the 13 patient experience topic areas (0 = lowest score, 100 = highest score). Patients from very remote and outer regional EDs reported the highest scores for the topic Environment and facilities, and remote facility patients reported the highest scores for the topic Leaving the ED - Delays. The same two topic areas were scored most highly by patients from smaller facilities in comparison to principal referral hospital EDs.

CONCLUSIONS

Patients attending smaller and more rurally located EDs reported more positive experiences than those attending larger, metropolitan EDs on two of the 13 topic areas. However, these differences were marginal. Future research should aim to determine what constitutes clinically meaningful differences between groups when comparing patient-reported experience scores, and understand the characteristics of small and rural EDs that may be associated with better patient experiences.

The Relationship of Hospital CEO Characteristics to Patient Experience Scores

EXECUTIVE SUMMARY

Efforts by hospitals to improve patient experience continue as changes in policy such as the Affordable Care Act of 2010 have made patient experience a cornerstone of promoting greater value in the United States. Hospital CEOs play an important role in promoting positive patient experiences as they set the organizational vision and strategic goals and can execute change to support positive experiences.This study assessed whether three CEO characteristics-education, tenure with the organization, and gender-were associated with patient experience scores of California hospitals in 2013 and 2014. Using a pooled, cross-sectional design with ordinary least squares regression to account for other hospital and market characteristics, the analysis indicated that hospitals with female CEOs and longer-tenured CEOs were associated with more positive patient experience scores. Higher levels of education were not significantly associated with patient experience scores. Overall, the model covariates accounted for approximately 14.0% of the variance in patient experience scores between hospitals, with CEO characteristics accounting for approximately 2.4% of this variation. Such findings highlight the important yet emerging role of CEO characteristics when accounting for patient experience.

[Shared decision making in breast care centres in North Rhine-Westphalia: results of a 10-year trend analysis]

BACKGROUND

Although shared decision making (SDM) has been gaining importance in German health services for some time now, the state of its implementation is still unknown. The aim of this study was to provide a valid trend analysis for SDM in breast care centres in the German federal state of North Rhine-Westphalia (NRW) for a period of 10 years.

METHODS

As part of an annual patient survey in breast care centres in NRW, two subscales of the Perceived Involvement in Care Scales (PICS) were used and analysed in multi-level models.

RESULTS

Data from nearly 40,000 patients could be analysed with consistently high response rates. In the observation period from 2006 to 2015 doctor facilitation and patient involvement increased on a scale from 1 to 4 of 3.1 to 3.4 and 2.6 to 2.8, respectively.

CONCLUSIONS

Despite the slight increases in the 10-year observation period a stable trend cannot be assumed. However, this study might be useful as a baseline for other studies on SDM implementation.

Influence of patient and hospital characteristics on inpatient satisfaction in China's tertiary hospitals: A cross-sectional study

BACKGROUND

Patient satisfaction has been seen as a key criterion when evaluating hospitals and is one of the main focuses of the current health-care reform in China. This paper aimed to explore patient- and hospital-level factors associated with inpatient satisfaction, which can provide policy implications for the evaluation and development of a patient-oriented health-care system.

METHODS

The paper analyses data from the 2017 China National Patient Survey which includes 20 300 inpatients from 131 tertiary hospitals across 31 provinces. Descriptive analysis and multivariable logistic regressions are conducted to identify key factors related to satisfaction.

RESULTS

Patient sociodemographic characteristics, including gender, age, income and insurance type, are found to be strongly associated with their satisfaction of inpatient experience. In terms of institutional characteristics, hospital type, size, staffing and financial performance are also significantly correlated with inpatient satisfaction. Patients are more satisfied with specialist hospitals and large hospitals measured by the number of beds and surgeries. Hospitals with higher nurse-to-bed ratio also receive more satisfaction. The financial performance of hospitals, however, is negatively associated with satisfaction.

CONCLUSION

Patient satisfaction contains unique information on service quality and thus should be incorporated into the matrix of hospital evaluation. Meanwhile, differences in patient composition must be adjusted to make fair comparisons across hospitals. Moreover, future reform needs to put greater efforts in the design of comprehensive public insurance scheme, efficient hospital structure and an overall well-functioning health-care delivery system in order to better serve patients in China.

The value of Facebook in nation-wide hospital quality assessment: a national mixed-methods study in Norway

Objectives

The objective was to assess the possibility of using a combination of official and unofficial Facebook ratings and comments as a basis for nation-wide hospital quality assessments in Norway.

Methods

All hospitals from a national cross-sectional patient experience survey in 2015 were matched with corresponding Facebook ratings. Facebook ratings were correlated with both case-mix adjusted and unadjusted patient-reported experience scores, with separate analysis for hospitals with official site ratings and hospitals with unofficial site ratings. Facebook ratings were also correlated with patient-reported incident scores, hospital size, 30-day mortality and 30-day readmission. Facebook comments from 20 randomly selected hospitals were analysed, contrasting the content and sentiments of official versus unofficial Facebook pages.

Results

Facebook ratings were significantly correlated with most patient-reported indicators, with the highest correlations relating to unadjusted scores for organisation (0.60, p<0.000) and nursing services (0.57, p<0.000). Facebook ratings were significantly correlated with hospital size (−0.40, p=0.003) and 30-day mortality (0.31, p=0.040). Sentiment analysis showed that 84.7% of the comments from unofficial Facebook sites included neutral comments that did not give any specific description of experiences of the quality of care at the hospital. Content analysis identified common themes on official and unofficial Facebook pages.

Conclusions

Facebook ratings were associated with patient-reported indicators, hospital size, and 30-day mortality. Qualitative comments from official Facebook are more relevant for hospital evaluation than unofficial sites. More research is needed on using Facebook ratings as a standalone indicator of patient experiences in national quality measurement, and such ratings should be reported together with research-based patient experience indicators and with explicit criteria for the inclusion of unofficial sites.

Relationship between employee engagement scores and service quality ratings: analysis of the National Health Service staff survey across 97 acute NHS Trusts in England and concurrent Care Quality Commission outcomes (2012-2016)

OBJECTIVE

This research explores measures of employee engagement in the National Health Service (NHS) acute Trusts in England and examines the association between organisation-level engagement scores and quality ratings by the Care Quality Commission (CQC).

DESIGN

Cross-sectional.

SETTING

97 acute NHS Trusts in England.

PARTICIPANTS

97 NHS acute Trusts in England (2012-2016). Data include provider details, staff survey results and CQC reports. Hybrid Trusts or organisations affected by recent mergers are excluded.

OUTCOME MEASURES

Analysis uses organisation-level employee engagement and CQC quality ratings.

RESULTS

Employee engagement is affected by organisational factors, including patient bed numbers (β=-0.46, p<0.05) and financial revenue (β=0.38, p<0.05). CQC ratings are predicted by overall employee engagement score (β=0.57, p<0.001) and financial deficit (β=-0.19, p<0.05). The most influential employee engagement dimension on provider ratings is 'advocacy' (λ=0.54, p<0.001). Analysis supports the notion that employee engagement can be predicted from advocacy scores alone (eigenvalue=4.03). Better still, combining advocacy scores from the previous year's survey or adding in motivation scores is a highly reliable indication of overall employee engagement (95.4% of total variance).

CONCLUSIONS

NHS acute Trusts with high employee engagement scores tend to have better CQC ratings. Trusts with a high financial deficit tend to have lower ratings. Employee engagement subdimensions have different associations with CQC ratings, the most influential dimension being advocacy score. A two subdimension model of engagement efficiently predicts overall employee engagement in NHS acute Trusts in England. Healthcare leaders should pay close attention to the proportion of employees who would recommend their organisation as a place to work or receive treatment, because this is a proxy for the level of engagement, and it predicts CQC ratings.

An Evolutionary Computation Approach for Optimizing Multilevel Data to Predict Patient Outcomes

Widespread adoption of electronic health records (EHR) and objectives for meaningful use have increased opportunities for data-driven predictive applications in healthcare. These decision support applications are often fueled by large-scale, heterogeneous, and multilevel (i.e., defined at hierarchical levels of specificity) patient data that challenge the development of predictive models. Our objective is to develop and evaluate an approach for optimally specifying multilevel patient data for prediction problems. We present a general evolutionary computational framework to optimally specify multilevel data to predict individual patient outcomes. We evaluate this method for both flattening (single level) and retaining the hierarchical predictor structure (multiple levels) using data collected to predict critical outcomes for emergency department patients across five populations. We find that the performance of both the flattened and hierarchical predictor structures in predicting critical outcomes for emergency department patients improve upon the baseline models for which only a single level of predictor—either more general or more specific—is used (p < 0.001). Our framework for optimizing the specificity of multilevel data improves upon more traditional single-level predictor structures and can readily be adapted to similar problems in healthcare and other domains.

How do hospital-specialty characteristics influence health system responsiveness? An empirical evaluation of in-patient care in the Italian region of Emilia-Romagna

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply-side factors. This paper addresses that research gap by analysing the role of hospital-specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in-patients treated in public hospitals within the Italian Region of Emilia-Romagna. The analysis is carried out by adopting a 2-step procedure. First, we use patients' self-reported data to derive 5 measures of responsiveness at the hospital-specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross-sectional regressions to investigate the association between patients' responsiveness and potential supply-side drivers, including waiting times, staff workload, the level of spending on non-clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply-side drivers considered.

An Exploration of Interactive Wayfinding Displays in Hospitals: Lessons Learned for Improving Design

This research examined the usability and effectiveness of three large hospitals’ wayfinding interfaces. Participants recruited from three hospitals completed various tasks using the wayfinding interface. Errors and issues consistently observed were organized and developed into insights and recommendations, such as classifying information according to user expectations, including a universal search, minimizing unnecessary on-screen information, adhering to platform standards, presenting visual aids effectively, orienting navigation information effectively, and providing relevant environmental cues. Results from this paper will help inform researchers and designers to develop necessary guidelines when creating and iterating wayfinding interfaces, both in large multi-building hospitals and similar settings.

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy

Background

Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team.

Methods

The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients’ experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users.

Results

A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01).

Conclusion

The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

Investigation of the degree of organisational influence on patient experience scores in acute medical admission units in all acute hospitals in England using multilevel hierarchical regression modelling

OBJECTIVES

Previous studies found that hospital and specialty have limited influence on patient experience scores, and patient level factors are more important. This could be due to heterogeneity of experience delivery across subunits within organisations. We aimed to determine whether organisation level factors have greater impact if scores for the same subspecialty microsystem are analysed in each hospital.

SETTING

Acute medical admission units in all NHS Acute Trusts in England.

PARTICIPANTS

We analysed patient experience data from the English Adult Inpatient Survey which is administered to 850 patients annually in each acute NHS Trusts in England. We selected all 8753 patients who returned the survey and who were emergency medical admissions and stayed in their admission unit for 1-2 nights, so as to isolate the experience delivered during the acute admission process.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multilevel logistic regression to determine the apportioned influence of host organisation and of organisation level factors (size and teaching status), and patient level factors (demographics, presence of long-term conditions and disabilities). We selected 'being treated with respect and dignity' and 'pain control' as primary outcome parameters. Other Picker Domain question scores were analysed as secondary parameters.

RESULTS

The proportion of overall variance attributable at organisational level was small; 0.5% (NS) for respect and dignity, 0.4% (NS) for pain control. Long-standing conditions and consequent disabilities were associated with low scores. Other item scores also showed that most influence was from patient level factors.

CONCLUSIONS

When a single microsystem, the acute medical admission process, is isolated, variance in experience scores is mainly explainable by patient level factors with limited organisational level influence. This has implications for the use of generic patient experience surveys for comparison between Trusts and should prompt further research to explore if more discriminant surveys can be developed.

Relationships between Medicare Advantage contract characteristics and quality-of-care ratings: an observational analysis of Medicare Advantage star ratings

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) publishes star ratings on Medicare Advantage (MA) contracts to measure plan quality of care with implications for reimbursement and bonuses.

OBJECTIVE

To investigate whether MA contract characteristics are associated with quality of care through the Medicare plan star ratings.

DESIGN

Retrospective study of MA star ratings in 2010. Unadjusted and adjusted multivariable linear regression models assessed the relationship between 5-star rating summary scores and plan characteristics.

SETTING

CMS MA contracts nationally.

PARTICIPANTS

409 (71%) of a total of 575 MA contracts, covering 10.56 million Medicare beneficiaries (90% of the MA population) in the United States in 2010.

MEASUREMENTS

The MA quality ratings summary score (stars range from 1 to 5) is a quality measure based on 36 indicators related to processes of care, health outcomes, access to care, and beneficiary satisfaction.

RESULTS

Nonprofit, larger, and older MA contracts were more likely to receive higher star ratings. Star ratings ranged from 2 to 5. Nonprofit contracts received an average 0.55 (95% CI, 0.42 to 0.67) higher star ratings than for-profit contracts (P  < 0.001) after controls were set for contract characteristics.

LIMITATION

The study focused on persons aged 65 years or older covered by MA.

CONCLUSION

In 2010, nonprofit MA contracts received significantly higher star ratings than for-profit contracts. When comparing health plans in the future, the CMS should give increasing attention to for-profit plans with lower quality ratings and consider developing programs to assist newer and smaller plans in improving their care for Medicare beneficiaries.

PRIMARY FUNDING SOURCE

None.

Meeting patients' health information needs in breast cancer center hospitals - a multilevel analysis

BACKGROUND

Breast cancer patients are confronted with a serious diagnosis that requires them to make important decisions throughout the journey of the disease. For these decisions to be made it is critical that the patients be well informed. Previous studies have been consistent in their findings that breast cancer patients have a high need for information on a wide range of topics. This paper investigates (1) how many patients feel they have unmet information needs after initial surgery, (2) whether the proportion of patients with unmet information needs varies between hospitals where they were treated and (3) whether differences between the hospitals account for some of these variation.

METHODS

Data from 5,024 newly-diagnosed breast cancer patients treated in 111 breast center hospitals in Germany were analyzed and combined with data on hospital characteristics. Multilevel linear regression models were calculated taking into account hospital characteristics and adjusting for patient case mix.

RESULTS

Younger patients, those receiving mastectomy, having statutory health insurance, not living with a partner and having a foreign native language report higher unmet information needs. The data demonstrate small between-hospital variation in unmet information needs. In hospitals that provide patient-specific information material and that offer health fairs as well as those that are non-teaching or have lower patient-volume, patients are less likely to report unmet information needs.

CONCLUSION

We found differences in proportions of patients with unmet information needs between hospitals and that hospitals' structure and process-related attributes of the hospitals were associated with these differences to some extent. Hospitals may contribute to reducing the patients' information needs by means that are not necessarily resource-intensive.

Perceived quality of an alternative to acute hospitalization: an analytical study at a community hospital in Hallingdal, Norway

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient-staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.

Does feedback influence patient - professional communication? Empirical evidence from Italy

Healthcare providers often look for feedback from patient surveys. Does health-professional awareness of patient survey results improve communication between patients and providers? To test this hypothesis, we analyzed the data of two surveys on organizational-climate and patient experience in Italy. The two surveys were conducted in 26 hospitals in the Tuscany region and involved 8942 employees and 5341 patients, respectively. Statistical analysis showed that the patient experience index significantly improved by 0.35 points (scale: 0-100) when the professionals' knowledge of the patient survey results increased by 1%. These findings suggest that the control systems should focus more on the dissemination phase of patient survey results among health professionals in order to improve the quality of services.

How patients choose hospitals: Using the stereotypic content model to model trustworthiness, warmth and competence

In many countries, policy initiatives force the implementation of demand-driven healthcare systems to encourage competition among providers. When actively choosing hospitals, consumers can compare data on the quality of hospital performance among providers. However, patients do not necessarily take full advantage of comparative quality information but instead use a number of readily available proxies to evaluate provider trustworthiness. According to the stereotypic content model, organizational trustworthiness is built on stereotypical perceptions of hospitals' competence and warmth, reflected by visible hospital characteristics such as ownership and teaching status, and size. We introduce a theoretical framework on stereotypic quality perceptions that brings together fragmented findings in health services research on patient quality expectations of hospital characteristics. The model provides a basis for further research and recommendations for improved hospital communication strategies. The study suggests that researchers as well as hospital management should pay more attention to stereotypical patient quality perceptions and their impact on hospital choice to understand patients' quality evaluations better.

Do breast cancer patients receive less support from physicians in German hospitals with high physician workload? A multilevel analysis

OBJECTIVE

Little is known about how organizational factors influence the patient-physician interaction. This study investigates the relationship between physician workload in hospitals and breast cancer patients' perceptions of the support provided by physicians.

METHODS

Data from 1844 newly diagnosed breast cancer patients treated in 35 breast cancer center hospitals in the German state of North Rhine-Westphalia in 2010 were combined with data from 348 physicians from the same hospitals. Multilevel logistic regression models were calculated using 31 hospitals with complete patient and physician data. Patients' perceptions of physician support were studied in relation to physician workload in hospitals.

RESULTS

Breast cancer patients perceived themselves as receiving less support from physicians when treated in hospitals where physicians reported working more overtime hours and having less time for patient care.

CONCLUSION

This study provides preliminary evidence of the association between the hospital work environment and physicians' ability to support patients. Future studies should investigate the extent to which physicians' interaction performance can be modified through hospital-level interventions aimed at managing workload.

PRACTICE IMPLICATIONS

By approaching the problem of physician staffing in hospitals and investing in the hospitals' working conditions, health policy and hospital management could create conditions conducive to better patient-physician interaction.

The Cancer Patient Experiences Questionnaire (CPEQ): reliability and construct validity following a national survey to assess hospital cancer care from the patient perspective

OBJECTIVES

Patient experience questionnaires have been criticised owing to the lack of supporting psychometric evidence. The objective of this study was to describe the development and psychometric evaluation of the Cancer Patient Experiences Questionnaire (CPEQ) in Norway.

DESIGN

Questionnaire development was based on a literature review of existing questionnaires, patient interviews, expert-group consultations, pretesting of questionnaire items and a national survey. Psychometric evaluation included exploratory and confirmatory factor analysis, and tests of internal consistency reliability and test-retest reliability.

SETTING

Data were collected using a postal survey of cancer patients attending 54 hospitals in all 4 health regions. The subjects were 14 227 adult cancer patients who had attended an outpatient clinic or who had been discharged from an inpatient ward. Patients with all types of cancer were included. Data quality, internal consistency reliability and construct validity were assessed.

RESULTS

Of the 13 846 patients who received the CPEQ, 7212 (52%) responded. Exploratory factor analysis identified six scales of outpatient experiences relating to nurse contact, doctor contact, information, organisation, patient safety and contact with next of kin, and seven scales of inpatient experiences, with the addition of hospital standard to the aforementioned scales. All but two of the scales met the criterion of 0.70 for Cronbach's α testing, and test-retest correlations ranged from 0.57 to 0.85. Confirmatory factor analysis supported the interpretation of six and seven scales for outpatients and inpatients, respectively. Statistically significant associations based on explicit hypotheses provided evidence for the construct validity of the scales. One additional scale measuring the hospital level was identified (α=0.85).

CONCLUSIONS

The CPEQ is a self-report instrument that includes the most important aspects of patient experiences with cancer care at hospitals. The instrument was tested following a national survey in Norway; good evidence is provided herein for the internal consistency reliability, test-retest reliability and construct validity.

Associations between hospital and patient characteristics and breast cancer patients' satisfaction with nursing staff

BACKGROUND

Only a few studies have investigated the association between hospital characteristics and breast cancer patients' satisfaction with nursing staff.

OBJECTIVE

The aim of this study was to determine whether the satisfaction of newly diagnosed breast cancer patients with nursing staff correlates with hospital characteristics after taking the relevant patient characteristics into account.

METHODS

Multilevel regression analysis was applied, combining survey data from newly diagnosed breast cancer patients regarding their characteristics and satisfaction with nursing staff with data on the characteristics of the hospitals in which the patients were treated.

RESULTS

Data from 2945 patients from 81 hospitals were analyzed in multilevel logistic regression models. The patients were significantly more likely to be satisfied with the nursing staff in hospitals that employed breast care nurses (BCNs) at the time of the survey. At the patient level, patients were significantly more likely to be satisfied with nursing staff if the patients were native speakers and rated their own health more highly. Cross-level interaction analysis suggested that the increased patient satisfaction with nursing staff that resulted from employing BCNs was largely limited to native German-speaking patients.

CONCLUSIONS

The results demonstrate that patient satisfaction with nursing staff is higher if BCNs are employed in the treatment hospital. However, only the satisfaction of native speakers was significantly higher when BCNs were employed.

IMPLICATIONS FOR PRACTICE

These findings suggest that hospitals should invest in employing specialist nurses. Special attention should be paid to the care of non-native-speaking patients.

A review of hospital characteristics associated with improved performance

PURPOSE

The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance.

DATA SOURCES

The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles.

STUDY SELECTION

and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume.

CONCLUSION

There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Patients' perceived support from physicians and the role of hospital characteristics

OBJECTIVE

Through patient-physician communication, physicians can support breast cancer patients in coping with the diagnosis and treatment of their cancer. Research on the influence of hospital characteristics on patient-reported outcomes suggests that patient-physician communication may be shaped by the hospital environment. The aim of this study is to investigate the relationship between hospital characteristics and breast cancer patients' perceptions of the support provided by physicians.

DESIGN

Data from two cross-sectional surveys conducted in 2007 were combined and hierarchical logistic regression models were calculated.

SETTING

Newly diagnosed breast cancer patients treated in breast center hospitals in North Rhine-Westphalia and at least one key person from these hospitals were surveyed.

PARTICIPANTS

Data from 3285 newly diagnosed breast cancer patients and 172 key persons from 87 breast center hospitals were used.

MAIN OUTCOME MEASURE

The patients' perceptions of support from physicians were measured with three items from the Cologne Patient Questionnaire. Physician support was studied in relation to patient characteristics as well as hospital structure and processes.

RESULTS

The multilevel model showed that breast cancer patients perceived themselves as receiving less support from the physician when there were problems within the hospitals' organization of care, independent of patient characteristics.

CONCLUSION

This study provides preliminary evidence that the quality of patient-physician communication depends not only on the patient or physician but also on hospital organization. Further studies should be conducted to determine the extent to which interventions for improving quality at the hospital level can modify physician communication performance.

Contemporary performance of U.S. teaching and nonteaching hospitals

PURPOSE

To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics.

METHOD

The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards).

RESULTS

Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care).

CONCLUSIONS

Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

[Usefulness of multilevel analysis of satisfaction questionnaires on clinical units and medical specialties]

OBJECTIVES

Evaluate the usefulness of multilevel analysis applied to satisfaction surveys to assess the ambulatory care offered by the Clinical Units and Medical Specialties.

METHODS

Telephone surveys were conducted on 6,922 patients seen in outpatient visits in the Navarra Health System in order to assess 94 Clinical Units and 37 Medical Specialties. A hierarchical analysis was then performed at 3 levels (patients, Clinical Units and Medical Specialties).

RESULTS

The patient explained between 91.7% and 99.3% of the variability in the satisfaction survey scores. The patient perception of service quality also depends of the clinical unit, in 18 out of 20 items analysed, the variance related to the Clinical Unit was statistically significant, and ranged from 0.9% and 8.3%. The Medical Specialty explained 4.2% of the variability in only one item. Patients aged under 65 years, patients seen in first visit, and those who were seen at tertiary hospitals gave the lowest scores.

CONCLUSIONS

Multilevel analysis is a useful tool to analyse and compare satisfaction survey results, as it can correctly distinguish the different Clinical Units of a health service, and this is a key element in the management of these Units. Moreover, it gives the percentage of variability due to each level and which variables predict the quality of service obtained.

A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety

OBJECTIVES

The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing.

DESIGN

This is an observational cross-sectional study using survey methods.

SETTING

Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey.

PARTICIPANTS

All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture.

OUTCOME MEASURES

Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures.

RESULTS

Quality system, nurse-physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses' affiliations to medical department and hospital type.

CONCLUSIONS

Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care.

A simple approach to fairer hospital benchmarking using patient experience data

OBJECTIVE

To determine the factors contributing most to variability in patient experience in order to present approaches for fairer benchmarking of hospitals and for quality improvement.

DESIGN

Secondary analysis of data from a widely used survey on patient experience.

SETTING

Inpatients from all 24 acute hospitals in the Canton of Bern in Switzerland. Data collection followed the standardized and validated Picker Institute methodology for a period of 13 weeks in the fall/winter of 2005.

PARTICIPANTS

Inpatients age 18 years and older (n = 14 089), discharged within the sampling period.

MAIN OUTCOME MEASURES

'Patient experience', measured by the total Picker Problem Score (PPS) and by six domain scores (care, communication, respect, cooperation, organization, discharge management).

RESULTS

In regression analysis, the patient factors self-reported health, age and education explained the highest proportion of variability in the PPS (4.8, 2.2 and 0.7%, respectively). Multiple linear adjustment for factors associated with patients removed between 29 and 33% of variability between hospital categories. The domain score means varied from under 5% for 'respect towards the patient' to 34% for 'discharge management'. Ranking of hospitals by domain scores differed from the ranking based on the total PPS.

CONCLUSIONS

Statistical adjustment for patient mix and additional stratification for some hospital factors make benchmarking using patient survey data fairer and more transparent. Use of our approach for presenting quality data may make interpretation easier for the different target groups and may enhance the relevance of such information for decision-making.

Is there an association between hospital accreditation and patient satisfaction with hospital care? A survey of 37,000 patients treated by 73 hospitals

OBJECTIVE

In many countries hospitals are undergoing accreditation as mandatory or voluntary measures. It is believed that accreditation positively influence quality of care and patient satisfaction. This survey aims at assessing the relationship between patient satisfaction and accreditation status.

DESIGN

Between January and May 2007, 4 weeks after their discharge, 78 508 patients from 328 departments in 73 hospitals received a validated questionnaire. Data from 36 777 patients (response rate 55%) were available for analyses.

MAIN OUTCOME MEASURES

Recommendation rate was used as primary endpoint, which was available from 35 945 patients. To address the clustering of patients within hospitals, we applied univariate and multivariable generalized estimating equations. As covariates we used 'gender' and 'age' at the patient level and the 'number of beds' and 'hospital teaching status' at the hospital level.

RESULTS

Overall and not addressing the clustering, 66.3% of all the patients recommend their hospital to others. This recommendation, however, was not related to the accreditation status in the univariate analyses (odds ratio (OR) for accreditation ('yes') and recommendation ('yes') 0.99, 95% confidence interval (CI) 0.85-1.16, P= 0.92). This result was similar in the multivariable regression model adjusted for clustering (OR = 0.98, 95% CI 0.84-1.13, P= 0.74).

CONCLUSIONS

Our results support the notion that accreditation is not linked to measurable better quality of care as perceived by the patient. Hospital accreditation may represent a step towards total quality management, but may not be a key factor to quality of care measured by the patient's willingness to recommend.

Challenging the holy grail of hospital accreditation: a cross sectional study of inpatient satisfaction in the field of cardiology

BACKGROUND

Subjective parameters such as quality of life or patient satisfaction gain importance as outcome parameters and benchmarks in health care. In many countries hospitals are now undergoing accreditation as mandatory or voluntary measures. It is believed but unproven that accreditations positively influence quality of care and patient satisfaction. The present study aims to assess in a defined specialty (cardiology) the relationship between patient satisfaction (as measured by the recommendation rate) and accreditation status.

METHODS

Consecutive patients discharged from 25 cardiology units received a validated patient satisfaction questionnaire. Data from 3,037 patients (response rate > 55%) became available for analysis. Recommendation rate was used as primary endpoint. Different control variables such as staffing level were considered.

RESULTS

The 15 accredited units did not differ significantly from the 10 non-accredited units regarding main hospital (i.e. staffing levels, no. of beds) and patient (age, gender) characteristics. The primary endpoint "recommendation rate of a given hospital" for accredited hospitals (65.6%, 95% Confidence Interval (CI) 63.4 - 67.8%) and hospitals without accreditation (65.8%, 95% CI 63.1-68.5%) was not significantly different.

CONCLUSION

Our results support the notion that - at least in the field of cardiology - successful accreditation is not linked with measurable better quality of care as perceived by the patient and reflected by the recommendation rate of a given institution. Hospital accreditation may represent a step towards quality management, but does not seem to improve overall patient satisfaction.

The prisoner as patient - a health services satisfaction survey

BACKGROUND

There is evidence for higher morbidity among prison inmates than in the general population. Despite this, patient satisfaction with the prison health services is scarcely investigated. The aim of the present study was to investigate patient satisfaction with prison health services in Norway and to analyze possible patient and service effects.

METHODS

The survey took part in 29 prisons in the southern and central part of Norway, representing 62% of the total prison capacity in Norway. A total of 1,150 prison inmates with prison health services experiences completed a satisfaction questionnaire (90% response rate). The patients' satisfaction was measured on a 12-item index. Multilevel analyses were used to analyze both patient and service characteristics as predictors of satisfaction.

RESULTS

The study revealed high levels of dissatisfaction with prison health services. There were substantial differences between services, with between-service-variance accounting for 9% of the total variance. Satisfaction was significantly associated with a senior staff member's evaluation of the health services possessing adequate resources and the quality of drug abuse treatment. At the patient level, satisfaction was significantly associated with older age, frequent consultations and better self-perceived health.

CONCLUSION

Prison inmates' satisfaction with the health services provided are low compared with patient satisfaction measured in other health areas. The substantial differences observed between services - even when adjusting for several known factors associated with patient satisfaction - indicate a potential for quality improvement.

Organizational influences on patient perceptions of symptom management

We tested a theoretical model of the relationships of hospital context, nursing unit structure, and patient characteristics to patients' perceptions of the extent to which nurses met their expectations for management of troubling symptoms. In our sample of 2,720 patients randomly selected from 278 nursing units in 143 hospitals, we found that patient age was positively associated with patients' perceptions of symptom management. The proportion of registered nurses as caregivers on the unit was not a significant predictor of symptom management, but better work conditions on the unit (nurses' autonomy, participation in decision-making, and collaboration with other disciplines [relational coordination]) significantly contributed to patients' perceptions of better symptom management.

Women's views of postnatal care in the context of the increasing pressure on postnatal beds in Australia

BACKGROUND

Despite limited evidence evaluating early postnatal discharge, length of hospital stay has declined dramatically in Australia since the 1980s. The recent rising birth rate in Victoria, Australia has increased pressure on hospital beds, and many services have responded by discharging women earlier than planned, often with little preparation during pregnancy. We aimed to explore the views of women and their partners regarding a number of theoretical postnatal care 'packages' that could provide an alternative approach to early postnatal care.

METHODS

Eight focus groups and four interviews were held in rural and metropolitan Victoria in 2006 with participants who had experienced a mix of public and private maternity care. These included 8 pregnant women, 42 recent mothers and 2 male partners. All were fluent in English. Focus groups explored participants' experiences and/or expectations of early postnatal care in hospital and at home and their views of alternative packages of postnatal care where location of care shifted from hospital to home and/or hotel. This paper describes the packages and explores and describes what 'value' women placed on the various components of care.

FINDINGS

Overall, women expressed a preference for what they had experienced or expected, which may be explained by the 'what is must be best' phenomenon where women place value on the status quo. They generally did not respond favourably towards the alternative postnatal care packages, with concerns about any shorter length of hospital stay, especially for first time mothers. Women were concerned about the safety and wellbeing of their new baby and reported that they lacked confidence in their ability to care for their baby. The physical presence and availability of professional support was seen to alleviate these concerns, especially for first time mothers. Participants did not believe that increased domiciliary visits compensated for forgoing the perceived security and value of staying in hospital. Women generally valued staying in hospital for the length of time they felt they needed above all other factors.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Women were concerned about shortened postnatal length of hospital stay and these concerns must be considered when changes are planned in maternity service provision. Any moves towards shorter postnatal length of stay must be comprehensively evaluated with consideration given to exploring consumer views and satisfaction. There is also a need for flexibility in postnatal care that acknowledges women's individual needs.

Incorporating health care quality into health antitrust law

Background

Antitrust authorities treat price as a proxy for hospital quality since health care quality is difficult to observe. As the ability to measure quality improved, more research became necessary to investigate the relationship between hospital market power and patient outcomes. This paper examines the impact of hospital competition on the quality of care as measured by the risk-adjusted mortality rates with the hospital as the unit of analysis. The study separately examines the effect of competition on non-profit hospitals.

Methods

We use California Office of Statewide Health Planning and Development (OSHPD) data from 1997 through 2002. Empirical model is a cross-sectional study of 373 hospitals. Regression analysis is used to estimate the relationship between Coronary Artery Bypass Graft (CABG) risk-adjusted mortality rates and hospital competition.

Results

Regression results show lower risk-adjusted mortality rates in the presence of a more competitive environment. This result holds for all alternative hospital market definitions. Non-profit hospitals do not have better patient outcomes than investor-owned hospitals. However, they tend to provide better quality in less competitive environments. CABG volume did not have a significant effect on patient outcomes.

Conclusion

Quality should be incorporated into the antitrust analysis. When mergers lead to higher prices and lower quality, thus lower social welfare, the antitrust challenge of hospital mergers is warranted. The impact of lower hospital competition on quality of care delivered by non-profit hospitals is ambiguous.