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A case study on ineffective nursing communication and poor patient safety

As reimbursement and performance policies have become more normative within healthcare, the patient experience has become a metric to measure payment systems for quality. However, we still have much to learn about the concept of patient experience and its influence on how patients report satisfaction with their care. This article discusses challenges for measurement of the patient experience, such as lack of consistent terminology and multiple contributing factors, by reviewing a brief selection of selected literature to help readers appreciate the complexity of measurement.

Patient experience, patient satisfaction, pay for performance, quality care; Triple Aim, nursing practice, healthcare, measurement of quality performance, health systems, quality improvement Were it not for the mandate to a case study on ineffective nursing communication and poor patient safety on the metrics of the patient experience, we may have continued to value the concept but avoided the challenge of precision and definition around the term.

Measurement and understanding of the patient, caregiver, and family experience of healthcare provides the opportunity for reflection and improvement of nursing care and patient outcomes. The concept of patient experience, however, is surprisingly complex. Were it not for the mandate to report on the metrics of the patient experience, we may have continued to value the concept but avoided the challenge of precision and definition around the term.

Instead, as noted in a brief from the National Quality Forum, nursing leaders have put patient experience first on their list of organizational and patient care priorities National Quality Forum, 2011. Over time there has been a regulatory and clinical care response to the concept of patient satisfaction and patient experience.

We often measure patient satisfaction but the satisfaction score is based on many factors that a patient experiences before, during, and after an episode of care, along with characteristics of the care environment. Nurses, the primary caregivers in all health promoting environments, including hospitals, clinics, and community settings, have responded in various ways to regulatory and clinical mandates.

The purpose of this article is to describe the concept of patient experience and its impact on patient satisfaction within the contextual framework of payment systems for quality and the challenges of measurement, such as lack of consistent terminology and multiple contributing factors.

A brief review of selected literature can help readers to appreciate how these challenges may contribute to the complexity of measurement. To incentivize health systems to implement these goals, CMS created ways to reward innovation related to how these strategies are implemented across health systems.

Each of the six priority areas within the CMS Quality Strategy 2013 is an opportunity to engage patients, caregivers, and families, thereby bringing the experience of care into the quality equation. The Affordable Care Act Office of the Legislative Counsel, 2010 called for provisions that would improve outcomes of healthcare through a series of requirements designed to assure quality reporting for such processes as effective case management, care coordination, chronic disease management, and others.

Thus began a major focus on the development of measurement sets designed to collect and report on the quality of evidence-based clinical care within healthcare institutions.

Not only would the system measure quality, it was designed to eventually reimburse services based on quality outcomes. As the provisions of the ACA Office of the Legislative Counsel, 2010 have become integrated into regulation within health system reform and into care environments themselves, more specific measures for the concept of patient experience have been developed.

The set of measures for ACOs to capture patient experience includes: The National Quality Forum 2015 has included measures specific for patient experience with psychiatric care as well. As noted, since the Affordable Care Act became law in 2010, a case study on ineffective nursing communication and poor patient safety activity by healthcare leaders has taken place to develop ways to measure quality outcomes. Equal effort has been underway within healthcare systems to address the delivery of quality care.

The establishment and utilization of systems to reimburse providers and institutions based on quality performance is also well underway. Quality, efficiency, and affordability of healthcare have become the conceptual umbrella for a system that will pay for the provision of healthcare based on the quality of patient care.

One of the precursors to health system reform involving metrics associated with improving care was the development of specific aims to guide the work of quality. Without a focus on all three at the system level, outcomes may be less than desirable.

They described a system in balance as goals are pursued with a focus on ethics, equity across populations, and specific strategies to assure that the pursuit of one aim in isolation would not adversely impact the other aims. We might imagine how initiatives within a healthcare setting could have an unsettling impact on patient experience if, for example, cost cutting measures reduced the ratio of nurses to patients.

Equally variable and complex is the experience that an individual has with the healthcare they receive. Much of the literature that describes how patients view their healthcare experience has focused on patient satisfaction. The next section will briefly describe selected literature to illustrate challenges related to terminology and measuring the complexity of the patient experience and patient satisfaction with care. Review of Selected Literature Terminology: The literature reports studies that use both terms, but rarely defines either patient satisfaction or patient experience.

Perhaps this is because each term seems to be defined by the factors used to measure it. This section describes selected research that demonstrates the interchangeability and variability of terminology, illustrating the lack of conceptual clarity that can challenge accurate measurement.

The purpose of HCAHPS is to standardize the collection of data to measure patient perspectives on hospital care through a survey instrument. These factors are organized into nine topical areas: A number of studies whose purpose was to understand the response of patients to their hospital experiences utilized the HCAHPS survey to collect data.

The terms patient satisfaction and perceptions of the hospital experience are multidimensional terms and, in a sense, are characterized by the items in the HCAHPS survey such as communication with nurses and the responsiveness of staff. Two examples of this type of research are studies developed by a team of researchers who have explored factors in acute care settings that are associated with patient satisfaction.

Kahn, Iannuzzi, Stassen, Bankey, and Gestring 2015 studied 182 patients in trauma and acute care surgery settings to investigate predictors of patient satisfaction as measured by the HCAHPS survey. Their findings indicated that patient perception of interactions with the healthcare team strongly predicted patient satisfaction. Other factors associated with satisfaction included speedy responsiveness of staff, the hospital environment, and pain control. Similar findings were reported by Iannuzzi et al.

In this study, clinical complications in particular were associated with patient satisfaction scores, and although a number of other factors were associated with patient satisfaction, provider communication was the strongest predictor of high satisfaction.

Results showed that physician-patient communication during the preoperative experience was predictive of satisfaction.

The Patient Experience and Patient Satisfaction: Measurement of a Complex Dynamic

Patient satisfaction contributing to patient experience. They described the situation of patients weighing the service received against their expectation. If the service exceeds expectations, they judge quality to be high; the reverse is true if the care is below expectations. All of these dynamics impact how satisfied patients are with their experience of what they encounter in healthcare.

Their satisfaction may or may not actually be related to whether they received quality care or whether they had good clinical outcomes. Patient satisfaction and reimbursement. Johnston 2013 expressed concerns about the utilization of patient satisfaction scores to judge the performance of physicians or its use as a metric for reimbursing physicians for care. Johnston described an encounter with a patient receiving palliative care where the patient and the physician had different approaches and expectations about facing end of life.

These differences led to a less than satisfactory experience on the part of the patient, even though the physician used an evidence-based approach. The experience of this patient was very different from his expectation and equally distressing for the physician. Neither were very satisfied. Johnston 2013 also suggested that linking patient satisfaction to physician payment creates a dilemma for the provider who knows that a particular treatment may not lead to a satisfied patient or family.

The opposite view was reported by Riskind, Fossey, and Brill 2011 based on their belief that patient satisfaction, while time consuming, can have a positive effect on the success of a medical practice.

Their premise was that increased patient satisfaction, and the ability to measure those results, created a climate where providers began to understand that a successful medical practice was influenced by a case study on ineffective nursing communication and poor patient safety satisfied their patients were.

Benchmarking patient satisfaction goals to physician accountability enabled this practice to directly educate providers on the correlation among higher patient satisfaction and profitability, increased market share, employee and physician productivity, retention, and reduction of malpractice lawsuits.

Evaluate patient experience to determine patient satisfaction. The list of criticisms included such ideas as: Experiences that providers and patients have during a healthcare encounter seem to capture not just the clinical aspects of care, but many other non-clinical aspects that further illustrate the complexity of measurement of these concepts. What are those conditions within a healthcare encounter, particularly within a hospital environment, that may impact the patient experience and, therefore, his or her satisfaction?

Examples of these may include: Each of these conditions is discussed briefly below in the context of selected research studies. Predictors of patient satisfaction, patient perception and health related failures. Jackson, Chamberlin, and Kroenke 2001 examined the predictors of patient satisfaction in a general medical clinic. The authors utilized a satisfaction survey with eight predictors of satisfaction.

At subsequent intervals, the patients completed a different questionnaire with one overall satisfaction question. The authors found a high correlation between the overall satisfaction scores and their responses to the eight specific satisfaction questions. Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication in this study the providers were all physiciansand symptom outcomes.

Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication. A study by Gadalean, Cheptea, and Constantin 2011 examined factors that had the potential to impact patient satisfaction scores. This international study examined 39 factors related to satisfaction or dissatisfaction.

How communication problems put patients, hospitals in jeopardy

Factors that positively impacted satisfaction scores included: However, the only factors significantly related to satisfaction scores included compassionate treatment and prompt resolution of requests. Factors significant for dissatisfaction included facilities and accommodations; lack of privacy; room temperature; medical staff not present; nurse attention focused on devices rather than patients; no explanation about treatments; regarding patience as objects; noise; and lack of sleep.

The study also examined patient factors such as education level and diagnosis. The authors reviewed events that caused significantly poor outcomes in each of the triple aim categories. They provided examples of six clinical care and or health related failures that negatively impacted the quality of care, the patient experience, and the cost of the care. These events included unplanned hospital readmission within 30 days, nursing home admission, inappropriate initiation of hemodialysis, wrong-site surgery, intentional injury or maltreatment of a child, and overly invasive treatment of a preference-sensitive condition.

The authors developed an approach to identifying populations by risk of experiencing these failures and taking a preventive approach to avoiding the outcomes. For example, patient satisfaction was negatively impacted by the loss of independence as the result of a nursing home admission, or invasive treatment Lewis et al. Nurse burnout and patient satisfaction.

This study was conducted during a time when a national nurse shortage was raising concerns about nurse burnout and stressed nurse work environments. The authors used cross-sectional surveys of 820 nurses and 621 patients across 20 urban U.

They reported that patients cared for by nurses who were in a work environment with adequate staffing, good administrative support, and positive relations between physicians and nurses reported higher satisfaction with their care. Safety and patient satisfaction. The authors studied these relationships across three hospitals in acute care in-patient environments. One of their interests was the role that patients themselves play in improving patient safety and that patient perception and understanding of safety may influence better safety outcomes.

They were also interested in the types of experiences within hospital settings that may be predictive of satisfaction on the part of patients. The study conceptual framework, attribution theory, postulated that service quality impacted safety perceptions which in turn influenced patient satisfaction.

The a case study on ineffective nursing communication and poor patient safety findings from a sample of 996 acute care patients across the three hospitals suggested that patient safety did mediate the relationship between quality and satisfaction and that as patients became more satisfied with service quality they reported more positive experience with safety related activities and procedures.

Even the brief review of the literature above demonstrates the inconsistent terminology and multitude of contributing factors that provide challenges for accurate measurement of the patient experience and its contribution to patient satisfaction, or vice versa.

The complexity of this task can be daunting, but health systems have both acknowledged and have come to value the importance of the potential knowledge gained as it impacts patient care and outcomes. The next section will discuss several examples from clinical practice innovations or processes that have contributed to positive results.