Nursing Research Utilization

Nowadays it has become apparent that health care is a commodity purchased competitively. In any competitive market, the goal is to make profit. In order to increase the proportion of his\her customers, a health provider must create customer loyalty. To do this, taking into consideration that health care provision is a delicate industry, much more than technical and professional support is needed: they need a human factor. In 2005, a survey indicated that 65 percent of respondents deemed compassionate staff to be more valuable than technology. Patient satisfaction is not the only one sided ideal; it goes to serve both a patient and a healthcare service provider; patient satisfaction also goes into earning revenue for a hospital, in addition, to creating a congenial work environment. In the case of a community hospital, increased goodwill to the hospital from the local community shows increased patience satisfaction; conversely, disgruntled patients are difficult to work with, and they might air out their opinions to the public leading to the fact that a hospital might have a wounded self-image which is difficult to repair.

Patient satisfaction is not easy to achieve, especially in such hospital departments like the emergency department; however, there are measures that can be implemented in order to reduce dissatisfaction such as keeping the patient informed on the causes of the delay or the progress that a loved person doing. To achieve patient satisfaction faster and easier the duty does not solely lie on the employees and the physicians; the responsibility lies also on the society. Patients and relatives should be forth-coming with information and use the proper channels to address the grievance.

Communication is a paramount in achieving patient satisfaction. The patient should be consulted in decision making; this makes him/her feel appreciated and respected. In the health care system emotions flare up; thus, it is necessary to know how to diffuse these situations without causing further aggression. Once a hospital embarks on a patient satisfaction strategy, there is no turning back. Adequate measures must be put in place in order to sustain the patient’s satisfaction at the current level. Regular monitoring and evaluation of the patients` satisfaction strategy success or shortcomings should be carried out from time to time. It is a dynamic process; clear-cut techniques do not exist; instead, hospitals should tailor their policies to suit those that will satisfy the consumer and to terminate those which no longer benefit the society. At the micro-level, managers use patient satisfaction to set goals while at the national level, it is a tool for public accountability.

The objective of this paper is to establish a framework that a community hospital can use to increase patient satisfaction scores by 10 percentile for discharge instruction in Press Ganey Survey. This framework can be adopted by other hospitals of its size; however, this study does not exclude that large hospitals can use this framework, modifying it to suit their needs. Data, collected using various forms of data collection, is analyzed using such statistics tools as regression analysis and correlation. The paper contains a clear implementation plan of the proposed solution into a work setting.  In conclusion, the researcher gives suggestions that can be used to maintain, extend and terminate a proposed solution to the customer dissatisfaction problem.

Introduction

Patient satisfaction is not easy to achieve due to the complicated nature of health care needs. Patients are like other consumers; when they purchase a commodity or service, they expect to derive the greatest utility from the commodity or service purchased. There are several factors that make providing health care more complicated than any other service. The long hours of interaction between patients and nurses and/or doctors can put a strain on that relationship. When in hospital patients are more likely to experience tumultuous emotions that make them irritable; it burdens the care giver and influences the quality of care that patients receive; these emotions characterize intense feelings that are sometimes difficult to express. In recent years, there is a widening gap between technical expertise and patient tolerance. A fully equipped hospital by both technological facilities and staff may be lacking a patient understanding. An increasing number of people seeking medical care need an understanding team of medical practitioners.

Patient satisfaction is a paramount at both - macro- and micro –levels. At the macro-level, it can be used for public accountability and increasing competition, while social benefits are accrued by the patients at the micro-level. Patient satisfaction takes various dimensions depending on the demographic category that a patient belongs to. Many female patients seek empathy, professional co-ordination between the various departments and emotional care. The elderly, on the other hand, will consider a facility as satisfactory when it is physically easy to access, provides regular communication and staff identification. To achieve patient satisfaction when dealing with patients from different cultural backgrounds, hospital staff has to be aware and well-informed about the cultural diversity of their patients (Lee, 2004).

Organizational Overview

Community hospitals bring the intensely needed primary health care facilities to people in the remote areas. In addition, they reduce the pressure in other main hospitals. They provide services such as diagnostics, surgery, emergency care and intermediate care. Primary health care is the main form of health care offered by community hospitals. Primary health care system is a health care system where the general practitioner is responsible for running the hospital which includes patient selection, admission and management. The general practitioners work in liaison with nurses, consultants, midwives and other medical personnel when it is necessary. A community hospital’s loyalty lies on the patient. The main aim of community hospital is to provide health care to local community.

Statement of the problem

The problem is to increase patient satisfaction scores by 10 percentile for discharge instruction in Press Ganey Survey in a small community hospital.  Increasing patient satisfaction for hospitals has become almost mandatory; after the recent announcement by Medicare/Medicaid declaring that they would categorize hospitals according to patient satisfaction and use those results as a criterion of payment for performance. Press Ganey is a company which is solely concerned in assisting hospitals to achieve patient satisfaction, and it offers several components that can be used to identify the key components that should be used to measure patient satisfaction (Gupta, 2004).

Objectives

To demonstrate the need to achieve patient satisfaction

To develop a concise plan that administrators can use to ensure that their hospitals are patient centered.

To determine if patient satisfaction in a hospital correlates to an increase in its revenue

To determine what are the most influential factors in patient satisfaction.

Significance of the Research

Patient satisfaction is crucial because it is the most infallible measure of an organization's performance. In addition, it enhances community participation by exercising their democratic right. The purpose of this study is to establish the ways in which patient satisfaction can be increased (Press, 2005).

Organization of the Study

This study is organized in three main sections which are divided into sub sections. Chapter one is the introduction to the patient satisfaction topic and an organizational overview of community hospitals. In this chapter, the researcher also identifies the problem that this research paper wishes to resolve. A wise description on how the proposed solution will be implemented follows. It also contains literary support on the consistency of the solution to the current research knowledge. The feasibility of the proposed solution in a work setting is discussed in this chapter.

In order to increase patient satisfaction, health providers need to shift in order to have a more patient centered system. This will be done by use of follow up phone calls to the patients. The process of discharge starts at admission and ends at the day the patient is discharged from the hospital.  The follow up phone calls will be used to investigate on the patients experience in the hospital. Post discharge phone calls will enable the employees of the hospital to focus on the post-hospital phase of recovery. It will enable the physicians and nurses to follow up on the patients progress through family members. Physicians will keep track of the patients to ensure that verbal and written symptoms that are likely to come up during that period. This applies to both large and small community hospitals. Patient satisfaction can be achieved through quality assessment and quality improvements (Barton, 2003). The quality assessment is used to analyze the personal relationships between the patient and the physician. Quality improvement involves changes to the hospital operations in order to meet the expectations of a customer or patient that are outlined in the quality assessment process.

Quality assessment and improvement strategies of improving patient centeredness are wholesome strategies: they involve all the stakeholders’ concerned (employees, patients and physicians). In seeking the opinion of each person concerned, it will give a sense of team spirit to the strategy which will enhance cooperation and subsequently the strategy success.

The main aim of a community hospital is to offer primary health care services (Shi & Singh, 2005) at an affordable cost. Incorporating all the individuals into the project will not only help in achieving patient satisfaction but also attain its objective of involving the local community in its operations.

Literature Review

The solution of patient dissatisfaction can be achieved through a series of strategies. However, the most important of these strategies are quality assessment and quality improvement. In order for any health center to achieve patient satisfaction, an integral role must be played by the health care providers. When a patient searches a health care provider, just like in the case with any other service or product, he/she develops tastes and preferences and thus identifies attributes that he/she likes and chooses the health provider according to personal criteria. The hospital administration and staff should maintain the attributes of the hospital that attract the customer/patient to them whilst improving on what is necessary. For any hospital to be successful in achieving the objectives stated above, an evaluation to assess the current situation should be carried out. This information will enable the hospital to establish what is relevant to the patients, employees and physicians. Qualitative data can be collected through the appropriate methods of data collection such as interviews, questionnaires and observations. Qualitative data can be collected through surveys, Press Ganey data and process maps. The appropriate tools of statistics are used to determine the most significant variable; quantitative data will be analyzed using the regression model while quantitative data will be analyzed using correlation method.

Administrators use patient satisfaction surveys to take a glance into the inner operations of their hospitals. They are also used as a tool for setting administrative and management goals (Wadhwa, 2004). The evolution towards patient centeredness has increased in pace due to the shift from objective to subjective medicine, pressure to increase accountability and a wide variation in clinical practice.  However, patient satisfaction is not only beneficial to the patient but also to the community hospital; if the top level employees are satisfied with the quality of services in a hospital, then they will provide high quality care. High quality care will increase business in a hospital and increase the revenue of the hospital to break-even point. This is a formidable challenge, more so for community hospitals that must provide health care services at an affordable price while remaining solvent (Press, 2005). The use of the word customer instead of patient in the healthcare system is one of the most telling characteristics of a change from objective to subjective medicine. This places the concept that the health industry is a competitive market (Barton, 2003). This shift, therefore, should be accompanied by changing the way services are rendered; like in any competitive market, those organizations that take into consideration patient satisfaction are the ones that plough the benefits, mostly in terms of profits (Wadhwa, 2002). Quality can be used as a measure of a patient satisfaction by evaluating the personal comfort received during and after his/her stay in the hospital (Shi & Singh, 2005). According to Shi and Singh (2003) factors that show compassion will keep the existing customers of the hospital, creating customer loyalty.

Case studies have shown that organizations that deal with heath and social care are striving towards achievement of good relationships among the members of these organizations (Peck, 2003).For instance, a case study of an organization referred to as Community Development Health Network, displays the importance of maintaining good relationships. The aim of the organization is to do away with health inequalities on the basis of community development approach. It can be noted from the study that community development only occurs if good relationships are maintained. These good relationships will then lead to coordination of development activities. Therefore, it is important that good relationships are maintained during quality service provision to the service users. The organization was established in 1995 and it has achieved partial goals through the emphasis on the importance of the relationship with the service users. The organization is an example of the results achieved due to good relations maintained.

Generally, maintaining good relationships in health and social care is crucial, since it will lead to quality service provision. Good relationships between the service users and the caregivers will lead to trust between these two groups. As a result, the service users will be able to confide in the caregivers. This way, the caregivers will understand the needs of the service users in a clearer way. In the end, the services provided will match with those required. Since the caregivers are agents of the organization, the same trust is transferred to the organization. Also, maintaining good relations between the organizations and the caregivers will be a motivating factor to the caregivers. As a result, they will be enthusiastic about their work. This will benefit largely the service users.

The relationships in health and social care have greatly improved over time. This is mainly because of the participation of the society in the process of this service provision. This is evident through the already enacted Acts of Parliament in favor of these relationships. These include the Children’s Act of 1989, the NHS Community and Care Act of 1990 and the Mental Health Act among many others. The continuous participation of the government and the society has been of great significance towards enhancement of these relationships. It should be also noted that the awareness programs that are consistently implemented all over the world have played a great role in enhancement of these relationships.

In order to promote good partnerships in health and social care, local authorities should work together with the primary care trusts and other NHS members. This would enable them to contribute funds to a single pot. Eventually, they would provide better social care services. There could also be commissioning where duties are delegated from one leading company. This is already in practice for many learning disabilities. It is preferred because quality services are provided and organizational boundaries are closed.

The implementation of the plan has to start from the top level management. The hospitals administrators should come up with a list of departmental heads that will form a task force that will head the patient satisfaction implementation plan. The task force will be mandated with the responsibility of investigating the current level of patient satisfaction in the hospital. From this evaluation, they will establish the areas that need a lot of attention and those that need slight improvements. Since it is a community hospital, they should allow feedback from the actual users of the hospital as well as the employees. After the task force has gathered adequate information about the current situation, then the report can be presented to the board of directors with a clear plan on how to achieve or increase patient satisfaction. If the workers lack motivation and, thus, have a low performance rate then they should come up with moral boosters and training programs to create awareness on the need for patient satisfaction to the organization and their role in implementation of the plan should be clearly explained.

The board of directors would then mobilize the necessary resources required for this process. These resources may be in the form of hiring trainers who will train the hospital employees on patient satisfaction, or in the form of financial resources to conduct a survey and collect the necessary data. Monitoring of the plan could be done every six months through established sources of feedback. The task force would analyze the feedback given and through these make the necessary adjustments to the plan. Using the necessary tools of statistics the data collected by the Press Ganey Survey would generate percentile measures, which will show an increase or decrease in patient satisfaction.

The systems theory of change is a theory that views an organization as system held together by its different parts. According to this theory in order to change and to be effective all the elements of the organization must work together. A community hospital is no different from any other organization; therefore, all stakeholders (nurses, patients, physicians) should be involved in the process of change. According to this theory, the trigger for change is a conflict between the goals of the organization and those of its employees. Achieving patient satisfaction may at times be difficult for an organization because the employees may find it difficult to implement the changes in an already strenuous environment (Woodman, 1989).

Research Methodology. Outcome Measure

The extents to which the objectives of this study have been achieved are measured through the Press Ganey top 10 variables that highly correlate with patient satisfaction (see appendix 1). Press Ganey is a firm that specializes in selling the idea of patient satisfaction to hospitals and medical centers. The top 10 variables are reached after a series of research based on patients` feedback; they are thus reliable and valid as they are not based on the theoretical view of academicians but the practical experiences of the patients. Compassion and communication rate highly in these variables.  They do not contradict the theoretical perspective of patient satisfaction. A survey conducted in 2004 including 2350 patients showed that they would consider a hospital experience pleasant if they: were treated with compassion and respect; were in constant communication with the doctors and kept up to date with their progress and efficiency of response (Safavi, 2006).

Evaluation Data Collection

Data will be collected using surveys based on the Press Ganey list of questions which have the highest correlation to patient satisfaction. According to Press Ganey satisfaction report (2003) the criteria are the following - How well staff worked together to care about the patient; Overall cheerfulness of hospital ; Response to concerns/complaints made during the stay ; Amount of attention paid to patient`s personal and specific needs; Staff sensitivity to the inconvenience of hospitalization ; How well nurses kept the patient informed ; Efforts of the staff to include patients in decisions about their treatment; Nurses` attitude toward patient`s requests ; Skills of nurses and  their friendliness are the top ten drivers that had the highest correlation with patient satisfaction.(Lee, 2004).

This model was used in this paper in order to determine if the above variable improved customer satisfaction as well as to come up with a framework through which patient satisfaction can be evaluated or revised for future purposes. The variable also assisted the researcher in identifying which of the variables were most pertinent to the customer so that greater emphasis is put on them by the concerned stakeholders. Primary data is collected using mail-in questionnaires, focus group discussions, survey schedules, interviews and observation. In this case, follow up phone calls can also be a method of data collection

Follow up phone calls

The information will be collected from the patients after they have left the hospital. The main advantage of this method is that it is fast; however it is prone to technical interruptions. Patients who have also left the hospital find it a bother having to answer questions over the phone.

Mail-in Questionnaires

In this method of data collection respondents are expected to read through the questions and fill the answers in the spaces provided.

Merits

This method of collecting data is cheap, especially where the population is spread out over a large geographical area. Unlike in an interview it is free from the bias of the interviewer, especially in open-ended questionnaires where the respondents uses his/her own words. The respondents are also given adequate time to respond to the questions which ensures that they give well thought out answers that are clearly articulated. This method is convenient because it can reach respondents who are not easily approachable; in addition, large samples can make the results of the research more reliable.

Demerits

It is likely that there is a bias in response due to low return of the dully filled questionnaires. Another shortcoming of this method is that it is only applicable where the respondents are educated and speak one language.(Emory, 2008). Since the questionnaire is sent by mail, the researcher loses control of the questionnaire once it is sent. In addition, there is a possibility of ambiguous responses or omission of replies. Mail-in questionnaires are slow, and it is difficult to know if the respondents are truly representative (Emory, 2008).

Focus Group Discussions

This is meant to focus attention on the given experience of the respondent and its effects. The interviewer has the liberty to decide the manner and the sequence in which questions will be asked. The main task of the interviewer is to confine the respondent to the topic/

Merits

This method is particularly useful because the interviewer can elicit in-depth information about the topic from the respondent, which is essential in determining the variables of patient satisfaction. During research, the researcher may at times be met with resistance; in a focus group interview, the researcher will overcome this resistance thus obtaining an almost perfect sample of the population. This method rarely gives inconclusive results since there are no cases of non-response. Face to face questions may catch the respondent off guard forcing him to give spontaneous answers, which are remarkably honest, which contrasts the well thought out answers of a questionnaire. In research, it is particularly beneficial to find out why a certain variable behaves as it does. Focus group discussions enable the researcher to obtain supplementary information which may explain the respondent’s answers. Questions in this form of data collection can be tailored to suit the educational level of the respondent without losing the meaning.

Demerits

Bias may be caused by the interviewer effect; it occurs when the interviewer asks questions in a particular manner in order to get specific results. An effective interview presupposes proper rapport with the interviewers which is not always the case. The presence of the interviewer may at times excessively excite the interviewee, sometimes prompting him or her give imaginary information just to make the interview interesting. Patient satisfaction research is carried across the board; therefore, certain types of respondents such as important officials, or individuals who are high income earners may not be easily accessible.

Observation

Observation is a scientific tool of data collection. In the case observation is characterized by a careful definition of the units observed, the style of recording the observed information, standardized conditions of observations and the selection of pertinent data which is known as structured observation. It is mostly used with descriptive statistics. Descriptive statistics is the development of certain indices from raw data.  This analysis provides us with profiles of companies, workgroups, persons and other subjects on any of multiple characteristics such as size, efficiency or patient satisfaction (Emory, 2001). This sort of analysis may be in the form of one variable, two variables or several variables, which is described in a multivariate analysis.

Merits

If the observation is carried out accurately, then the subjective bias is eliminated. One key advantage of this type of method is that it relates to what is currently happening and is not influenced by past or future behavior. This method is independent from the respondent’s willingness to respond and is relatively less demanding of active cooperation on the part of respondents as happens to be the case in the interview or the questionnaire method. It is particularly suitable for studies in which the respondents cannot clearly articulate their feelings for one reason or another.

Limitations

The information provided by this method is very limited. In some cases, unforeseen factors may interfere with the observational task; in addition, the fact that some people are rarely accessible to direct observation creates obstacles to collect data effectively using this method.

Survey Schedules

Survey schedules differ from the questionnaires in that it is not mailed to the respondent. The survey schedule, preferably, should be filled in as the respondent fills in the checkout papers.

Merits

The respondent may seek clarification in questions that he or she does not understand or in the case where the schedule is in a language that they do not understand. The survey collection can be done at several collection points in the hospital. Regression analysis is the determination of statistical relationship where two or more variables are concerned. In this situation, there is more than one independent variable; therefore, it becomes a multiple regression analysis which is done using the ordinary least square method. Regression analysis only interprets what exists physically: there must be a physical relationship in which independent variable X affects dependent variable Y. The data collected for the purpose of this survey contains multiple variables; hence, a problem of multicollinearity might occur. Multicollinearity refers to a situation when two variables exhibit a high degree of correlation, but do not have a perfect linear relationship. In such situation, the researcher should only use one set of the independent variable to make an estimate.

For the most accurate results, one of the above methods of data collection can be used in tandem with another; however it is apparent that all the above methods of collecting the data require human capital in their implementation. The committee overseeing this program is thus mandated with the responsibility of hiring new personnel to carry out the data collection or to train its current employees on the various methods. The board should mobilize financial resources so in order to hire the necessary human capital. The writing material needed should be available all the time to avoid unnecessary delays and it should be presented in mostly used languages.

Evaluation

This stage involves a systematic review of success and failure of the proposed solution elements.. This implies that evaluation is a continuous exercise during the existence of the proposed solution and it is related to project monitoring. There is usually a mid-term and a terminal evaluation. Evaluation can also be undertaken when the proposed solution is faced by its first contingency. The evaluation is undertaken in the mid- and short-term phases. Short-term evaluation should be done within the first three months of implementation, while the mid-term solution should be done in the first three months.

Evaluation can be done by internal or external reviewers. Some organizations have monitoring and evaluation units. A community hospital may have an internal review system in the form of its board of directors. This board evaluates the task force that implements the proposed solution.  The hospital can also utilize the services of external reviewers. The board of directors and the administration should mobilize resources to facilitate the implementation. The resources will include human capital and financial support. An evaluation will provide the management with useful information to ensure efficient implementation.

Discussion

For any project to be successful clear guidelines must be set on how to achieve the objectives of the project and there must be a well stipulated framework on how to respond to contingencies. All organizations have a group of people with well outlined job descriptions to ensure its objectives are reached; similarly, to ensure that the objective of this paper is reached, the hospital should identify a group of people with clearly identified roles to ensure that patient centeredness is achieved. A committee should be set up, and a taskforce that would be working directly with the focus groups should be appointed..

Focus Group Discussions

To ensure the success and continuity of this project the community should establish focus groups. Patient focus groups will be useful as they will provide the concerned stakeholders with the necessary in depth analysis of the hospital made from the customer’s perspective. Focus groups allow the patient to express an opinion on the possible solution to the problem. This gives the patient/customer a feeling to be involved in the entire process. The hospital administration should identify a committee that will be responsible for identifying the patients who will take part in the survey (Quinn, Jacobsen, Albrecht, Ellison, Newman, Bell, & Ruckdeschel, 2004.) The committee should oversee the focus group discussions and should refrain from making comments or asking questions which would influence the direction of the response.

Employee Interviews

Patient satisfaction is multifaceted; it can take the perspective of the clinical doctor, the employees or the patient. In order to achieve an all round response rate, the task force should conduct employee interviews. Employee interviews will be useful in understanding the employee’s view of patient satisfaction. Focus groups cannot be formed from employees as they will present a prejudiced outcome as some of the responses will be influenced by personal emotions or fear of speaking out due to the lack of anonymity. Allowing employees to voice their opinions will increase motivation and team spirit which will improve productivity. Hospitals, like other organizations are staffed with both the professional and supporting staff. To ensure that the responses obtained from the employee interview are unbiased, the interviews should be conducted in the various groups. The selection of the employees to take part in the interviews can be done by random selection in all departments; on the other hand, departmental heads can be asked by the taskforce to select from their employees those who will take part in the interview.

Disney Model

The hospital can also adopt the Disney model. Disney Company does not use customer satisfaction to assess whether its customers are satisfied with the services they receive; instead, they use customer loyalty. According to Lee it is not enough for a customer to have an experience that can be described as a warm or pleasant; the experience should be memorable so the patient will want to come back and enjoy the same service or will tell another person about the memorable experience; for example, if a patient is surrounded by  compassionate staff when he/she are in pain, it likely that the patient will remember that experience. That is why the hospital has to be staffed with caring people with a positive outlook towards life. Lee, however, is keen to note that  the attributes that a patient will rate as making experience memorable may not rate exceptionally high in the Press Ganey questions however, a lot of focus should be laid on these areas as they are the attributes that generate loyalty.

Adopting some or all of the above does not guarantee perfect results. The committee responsible for achieving patient satisfaction should carry out evaluation reports on any of the methods chosen. Should the proposed solution fail to work, then the task force should go back to the drawing board and analyze the proposed solution, this time taking into consideration the setbacks that made the project fail. The report should then be submitted to the board of directors who will come up with a new solution after a consultative meeting with the task force in-charge patient satisfaction.

If the results from the surveys indicate that the solution is unsuccessful or that the solution is no longer applicable to the hospitals situation, the committee should discuss the appropriateness of the solution and terminate the solution with the permission from the board of directors as continuing to use it will consume time and man-hours that could be used in implementing successful solutions.

The evaluation and monitoring of any project cannot be done without the responses from the concerned groups. Every concerned group, employees, patients and physicians should be asked to give feedback about effectiveness of the implemented solutions. . Suggestion boxes and questionnaires can be used to ensure anonymity. Interviews and observations are also appropriate as patient satisfaction can be felt in the general atmosphere of the hospital.