Between 2004 and 2006, thirty facilities took part in the Professional Liability (PL) Department’s Patient Experience survey. This review of Phase II was one of four parts of the Department’s Service Plan. This article gives an overview of the findings of this audit and shares some of the creative ideas that facilities have developed to serve varying types of patient populations under different circumstances.

It is simply good business to please the customer; and studies have been done to prove there is a correlation between unhappy patients and lawsuits. So it was with no surprise that the PL Consultants found active Patient Relations or Patient Satisfaction programs in the facilities surveyed. The various plans had differences which acknowledged the unique types of care offered and clientele served in varying types of communities. The Princeton consultants were interested in each facility’s results-oriented approach, and the level of creativity applied to each program.

As an overview, almost all facilities had full time employees in charge of patient relations; however, about half of these people also had other responsibilities besides patient satisfaction. Some facilities had more than one person assigned to the responsibility of patient relations, appointing specific people to be accountable for specialty areas such as the Emergency Department (ED) and Surgery. This special focus can be very effective, especially when there are other issues which make the patient/caregiver relationship more complex. These issues can be poverty, language obstacles, cultural barriers, and the unique needs of special populations such as the elderly.

All the facilities used some type of assessment tool. Many used Press Ganey’s mailed questionnaire, and a few used Jackson’s phone survey of discharged patients. Of interest was the finding that many facilities used a variety of different tools for different patient populations. For instance, the ordinary acute care patient might be mailed a Press Ganey survey, but a Behavioral Health assessment would be done in an individualized interview; the same institution would also use a follow-up phone survey, either Jackson or their own, to record the impressions of ED patients. In non-healthcare circumstances a business might wish to streamline these processes, but this decentralized approach to this information gathering is important in healthcare to obtain clear patient responses upon which to plan quality and patient safety improvements.

All facilities shared their patient survey results throughout their organization effectively, though a few did not routinely distribute a copy to the facility’s risk manager. Since the risk manager can determine areas of risk from patient satisfaction results, it is always suggested that they be included in this process too.  Some of the facilities had the ability to put their results on the hospital’s intranet so that all employees could view them. For institutions with computer capability of this nature, this is an excellent means of communication. It cannot, however, be relied on as the only interaction on this subject matter since some employees may not avail themselves of the information or may not have the time to use the computer to check it.

Almost all facilities consistently distributed Patient Rights Policies to their patients, maintained a complaint policy/procedure for patients and families to use, and maintained a patient education and/or Health Literacy Program. Approximately half of the facilities had disclosure policies, billing dispute policies, and complaint policies which allowed for grievances against physicians.

Patient Rights is a JCAHO initiative and was, therefore, expected by the consultants. Some patient representatives discussed the difficulties of effectively communicating much of this material to patients and families in the current short-stay world of medicine. Even longer staying patients are usually too ill to care to study written policies about their rights or to engage in the many educational and Literacy efforts that facilities provide. This issue does not have an easy answer, but a number of facilities have addressed it by putting up large posters in patient care areas; the posters remind patients and families of their rights, of the right to make complaints, and of the education which is available. Many facilities have also focused on staff education as a tool to accomplish a number of patient rights goals. When staff understand what is expected of them in the patient relations process, and (as some facilities are doing) when their performance review is partially based on their customer relations, they begin to pay more attention to informing patients about their rights and available education; they are also more interested in the results of patient satisfaction surveys and will work to improve their scores. Some facilities have also instituted staff awards programs for special recognition of patient service.

There is another problem that is experienced when attempting to adequately inform patients of the options available to them. In this situation, the issue is a challenge for the caregiver. Each facility was asked what efforts they made to involve patients and families in the care process. Many answers were routine; it was explained that patients were involved in their care through the question and answer process of assessments, and patients given a variety of opportunities to give feedback or ask questions. This certainly involves the patient, but most caregivers know that it is the skill of the individual assessor or the person who is interfacing with the patient/family which elicits input from them. And even the most skilled can experience problems with language and culture barriers. The PL consultants looked for very creative ways in which facilities had attempted to overcome this issue, since lack of communication with patients can be a precursor to lawsuits.

Some facilities have approached this issue with innovative approaches that are worthy of special mention. Rehabilitation and some long term care facilities have Interdepartmental Care (IDC) or Team meetings to address the needs of specific patients; they invite the patient and/or the family to attend and contribute to the agenda of these meetings. Similar facilities have patients attend focus groups regarding services. The JCAHO’s Speak Up initiative works for some institutions, but it is not appropriate for all patient populations; so some facilities are trying things like pre-operative pediatric tours, solicitation of patient issues during nursing and physician rounds, and special palliative care programs for end of life care. Institutions have even involved patients in the planning process for new specialty services.

A special question asked by the survey was whether the institution had developed a Patient-Family Council. Councils of this nature are committees which allow facility health care professionals, former patients, and members of their families to meet to discuss issues relevant to improving safe delivery of health care. Only a few facilities had tried anything like this; it is a relatively new concept and it can be quite disconcerting for healthcare professionals because the patients and families who are invited are often those which have experienced problems with the institution. These groups can be very effective but they need to be developed with thought and careful planning. It is usually appropriate to include a facilitator in each meeting. Results from facilities which have instituted these groups have been very positive.

Surveying patients and/or asking them for their input during and after care is very important because it keeps the patients and families involved, but the survey also checked to see what facilities were doing with the information they received. To assess a facility’s results-oriented approach, each institution was asked for measurable improvements that had been instituted as a direct result of patient satisfaction activities. Some answers were very general, noting improvements in scores, but over half gave specific initiatives and changes that had been put in place as a direct result of patient feedback. It is probably no surprise that the initiatives frequently involved dietary issues, call bell response times, and reduction in waiting times, especially in the ED. Another common area of improvement was in TV services.

Other changes which were made included noise reduction in various areas, development of pain relief teams, changes in nursing schedules to improve timeliness of medications, addition of waiting rooms, cleaning notices left in patient rooms by housekeeping staff, and multi-lingual signage. Parking was increased, free parking was offered to patients coming in for repetitive therapies, and dry erase boards in patient rooms to better enable communication between the cared for and caregivers. A significant number of facilities had responded to patient comments by increasing staff education about patient care needs and appropriate response.

The number of times food, TV, and waiting issues showed up in the initiatives indicated that basic areas of need were still the most important things to patients. Patients still wanted their food on time and at the right temperature; they still did not want to encounter long waits for care; and when they were hospitalized they wanted their TV to function appropriately, with the channels they wanted to watch. It can also be theorized that these are the items that patients and families were most comfortable critiquing; yet basic comfort and responsiveness remain vital to a patient’s stay within a healthcare facility. They are necessary to provide some sense of security at a time when the patient is feeling most vulnerable.

While healthcare is focusing on significant patient safety initiatives to protect patients against medical error, these comforts can seem small; yet they should not be forgotten. Princeton insured facilities have not lost sight of the importance of these measures.