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. 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. Finally, several examples from clinical practice will consider regulation, organizational environments, and research that can offer clarity around important factors that impact a patient’s experience and subsequent satisfaction with the provision of care.

Patient Experience and Payment Systems for Quality

Each of the six priority areas within the CMS Quality Strategy is an opportunity to engage patients, caregivers, and families, thereby bringing the experience of care into the quality equation. A confluence of policy priorities, stimulated by the Affordable Care Act (ACA; Office of the Legislative Counsel, 2010) and the Centers of Medicare and Medicaid Services (CMS) Quality Strategy (2013), has brought a focus on the need to deliver care that provides a quality patient experience within healthcare systems. For example, the CMS Quality Strategy (2013) identified six priorities that include: making care safer; ensuring individuals and families are engaged as partners in their care; promoting effective communication and coordination of care; promoting prevention; working with communities to promote healthy living; and making quality care more affordable. 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. The initial set of measures for the provision of care to Medicaid-eligible adults was issued in 2010 (Federal Register, 2010) and included a category of measures titled “Family Experiences of Care.”

As the provisions of the ACA have become integrated into regulation within health system reform and into care environments themselves, more specific measures for concept of patient experience have been developed. 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. Accountable Care Organizations (ACO), created under the ACA, are provider groups aligned around the goal of providing the highest quality care to Medicare patients. These ACOs participate in the Medicare Shared Savings Program to meet requirements specific to patient experience. The set of measures for ACOs to capture patient experience includes: timely care, provider communication, provider rating, access to specialty care, health promotion and education, shared decision-making, health status, courteous staff, care coordination, between visit communication, medication adherence education, and good use of patient resources (CMS Center for Medicare, 2015). 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, considerable 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.

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. Developed by the Institute for Healthcare Improvement (IHI) and known as the “Triple Aim,” the pursuit of improving the experience of care; improving the health of populations; and reducing per capita cost of healthcare struck a chord with organizations pursing strategies for managing quality and the cost of healthcare (Berwick, Nolan, & Whittington, 2008). Berwick et al. (2008) stressed that these three aims are interdependent. 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.

While we attempt to measure the individual’s satisfaction with their care, we know that it is the result of what they experience on several levels. It is evident that the process by which individuals become patients and how they develop a relationship with their health system and their healthcare providers is highly variable and depends on the individual’s demographics, socioeconomic status, family, health status, residence, genetics, employment, and many more factors. Equally variable and complex is the experience that an individual has with the healthcare they receive. While we attempt to measure the individual’s satisfaction with their care, we know that it is the result of what they experience on several levels. 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.

Challenges for Measurement: Review of Selected Literature

Terminology: Patient Satisfaction and Patient Experience
The terms ‘patient satisfaction’ and ‘patient experience’ are at times used interchangeably in the literature. The terms ‘patient satisfaction’ and ‘patient experience’ are at times used interchangeably in the literature. 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.

HCAHPS to measure patients’ perspectives. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey reflects patient perception of the care he or she experiences (HCAHPS, 2015). The purpose of HCAHPS is to standardize the collection of data to measure patient perspectives on hospital care through a survey instrument. Patients’ perspectives are measured through their responses to 21 factors. These factors are organized into nine topical areas: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. In the HCAHPS survey, these topics are indicators of satisfaction.

The HCAHPS survey reflects patient perception of the care he or she experiences. A number of studies whose purpose was to understand the response of patients to their hospital experiences utilized the HCAHPS survey to collect data. These studies examined the relationships of a variety of patient and hospital conditions to patient satisfaction or to the patient’s perceptions of their hospital experience. 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.

... provider communication was the strongest predictor of high satisfaction. 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. (2015) in their study of 978 patients hospitalized for surgical intervention. 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.

Utilizing a variation on HCAHPS, Schmocker, Stafford, Siy, Leverson, and Winslow (2015) examined the satisfaction of surgical patients using the Consumer Assessment of Healthcare Providers and Systems (S-CAHPS). The S-CAHPS focuses specifically on preoperative care and care on the day of surgery. Results showed that physician-patient communication during the preoperative experience was predictive of satisfaction.

... [Patients'] satisfaction may or may not actually be related to whether they received quality care or whether they had good clinical outcomes. Patient satisfaction contributing to patient experience. Kupfer and Bond’s study (2012) discussed the two terms in research and measurement and how patient satisfaction is related to how a service meets the expectation of the individual. 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. The researchers agreed that satisfaction with a service is correlated with the quality of the service, but they stressed that the dynamics behind patients’ perception of quality is also a function of their relationship with multiple providers, the environment, cultural influences, recovery, pain, and numerous other factors. 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 how 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. An interesting examination of common criticisms of patient experience measures by Price, Elliott, Cleary, Zaslavsky, and Hays (2014) questioned whether healthcare providers should be held accountable for a patient’s experience with his or her care. The list of criticisms included such ideas as:

• consumers do not have experience evaluating care quality;
• the term patient satisfaction is subjective and not valid;
• emphasis on improving patient experience may focus providers on fulfilling patient desires and lead to ineffective care;
• ultimately this emphasis may lead to a trade-off between the provision of a good experience and the provision of quality clinical care;
• patient scores are beyond a provider’s control;
• response rates to patient experience surveys are low; and
• customized ways to survey patients about their experiences exist and may contribute to bias.

Price et al. (2014) argued that it is highly important to capture the view of the patients in terms of their experience with care and that use of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) as a set of measures that may mediate some of these criticisms.

Measuring Complexity of the Patient Experience and Satisfaction with Care.
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. 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? A review of several studies examines these “conditions of care,” including factors that impact satisfaction. Examples of these may include: predictors of patient satisfaction, patient perception, and health related failures; the relationship between nurse burnout and patient satisfaction; and patient safety perceptions and patient satisfaction. 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 physicians), and symptom outcomes.

Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication... and symptom outcomes. A study by Gadalean, Cheptea, and Constantin (2011) examined factors that had the potential to impact patient satisfaction scores. The authors defined patient satisfaction as an “element of psychological health that influences the results of medical care” (pg. 41). This international study examined 39 factors related to satisfaction or dissatisfaction. The sample was 106 patients within an intensive care unit in a National Cancer Center in Romania. Factors that positively impacted satisfaction scores included: proper treatment; compassionate treatment; clear explanations about treatment; no pain; demonstration of proper concern; adequate contact with family; prompt resolution of requests; rest; quality and quantity of food; and properly addressing the patient. 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.

An intriguing article (Lewis, Kirkham, Duncan, & Vaithianathan, 2013) addressed the need for examining the Triple Aim as an integrated set of approaches. 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., 2013).

... 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. Nurse burnout and patient satisfaction. Another study examined the relationship between nurse burnout and patient satisfaction (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). 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.S. hospitals to examine the relationship among the nurse work environment, nurse burnout, and patient satisfaction with nursing care. 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. A study that focused on the role of patient safety perceptions in influencing patient satisfaction found that precautions around safety mediated the relationship between satisfaction and service quality (Rathert, May, & Williams, 2011). 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 study 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.

...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.

Examples from Clinical Practice

How have health systems, particularly nursing leaders, responded to both the demands of the regulatory environment (i.e., mandates from the ACA) and the need to improve the quality of healthcare overall to improve important metrics such as the cost-quality equation and the patient experience? Examples from clinical practice described below demonstrate how the implementation of technology, the influence of a positive work environment, and the process of care coordination can contribute to improved patient experiences and better patient satisfaction.

Implementation of Technology. Weston and Roberts (2013) examined this question through the lens of three nursing leaders from the perspective of leading clinical care in their large health systems (Department of Veterans Affairs, Kaiser Permanente, and Ascension Health). They offer several specific examples of process implementations in clinical practice. For example, the Department of Veterans Affairs utilized technology to create a portal for patients to access their personal health records. The primary purpose of this feature was to engage patients in their care. As a result of this innovation, access of the patient to their healthcare team increased along with patient satisfaction (Weston & Roberts, 2013). Kaiser Permanente created a roadmap to a system of alerts to support nurse decision making and to enhance best practices such as prevention of pressure ulcers and falls.

Positive work environment. Relationships have been noted between patient satisfaction and work environments where nurses thrive. A study by Kutney-Lee et al., (2009) examined the relationship among a nurse’s work environment and patient satisfaction. The researchers used the HCAHPS data to measure patient hospital experience. Three of the subscales in the Practice Environment Scale of the Nursing Work Index measured the nurse work environment. Measures of the quality of the work environment and staffing ratios were significantly associated with measures of patient satisfaction.

[One] found that Magnet® designation was significant in increasing six of the seven indicators of patient satisfaction. Another example of the influence of the nurse work environment is a recent study by Smith (2015) that reported findings on the relationship between Magnet®status of a hospital and patient satisfaction utilizing the HCAHPS survey. Smith sampled 2001 acute care hospitals who had complete data on all HCAHPS outcome data. This study found that Magnet® designation was significant in increasing six of the seven indicators of patient satisfaction. Interestingly, there was no significance in the patient rating of “always” on the question about “whether help was received when needed.

Care coordination. One final example that reinforces the importance of the relationship of patient satisfaction to care received is a research study that considered the association between care coordination and patient satisfaction (Wang, Mosen, Shuster, & Bellows, 2015). The researchers reported a positive association between care coordination and patient satisfaction with care that was focused on chronic disease management. With the current emphasis on care coordination, further research as to the impact of this coordination on patient satisfaction can help us to direct these initiatives.

Conclusion

...it is essential that we continue to explore this dynamic in greater detail. There is much to appreciate from this brief glimpse at some of the knowledge generated about the dynamic of patient experience and patient satisfaction.  We know that the concept of patient satisfaction is related to a patient’s direct and indirect experiences with the healthcare system and interaction with healthcare providers, particularly communication. We understand that the nurse’s work environment can impact patient satisfaction in positive and negative ways. We also understand that patients’ own experiences may not directly relate to the quality of the care  provided, but rather their expectations of what they believe should be provided or their expectations of their prognosis, treatment, family interaction, and environment. And yet, there is much still unknown. For clinical nurses and nursing leaders within healthcare systems and for policy makers who help to design the regulatory environment of healthcare, it is essential that we continue to explore this dynamic in greater detail. As patients, families, and providers collectively and collaboratively experience a healthcare encounter, we want to better understand the dynamic that brings together such factors as the expertise of the nurse, the support of the environment, organizational leadership, and the vast environmental, social, and cultural influences that contribute to patient satisfaction.

Author

Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN
Email: bb2509@columbia.edu

Bobbie Berkowitz is Dean and Professor of Nursing at Columbia University School of Nursing and Senior Vice President of the Columbia University Medical Center. She holds the title of Professor Emerita at the University of Washington where she was the Alumni Endowed Professor of Nursing and Chair of the Department of Psychosocial and Community Health and Adjunct Professor in the School of Public Health and Community Medicine. She served as a Consulting Professor with Duke University and the University of California at Davis. Previous positions include Deputy Secretary for the Washington State Department of Health and Chief of Nursing Services for the Seattle-King County Department of Public Health. Dr. Berkowitz was a member of the Washington State Board of Health, the Washington Healthcare Commission, and chaired the Board of Trustees of Group Health Cooperative. She currently serves as President of the American Academy of Nursing, and as a member of the boards of the Public Health Foundation, the Visiting Nurse Service of New York and the New York Academy of Medicine. Dr. Berkowitz is an elected Fellow/Member of the American Academy of Nursing, National Academy of Medicine, and the New York Academy of Medicine. She holds a PhD from Case Western Reserve University and Master of Nursing and Bachelor of Science in Nursing from the University of Washington. Her areas of expertise and research include public health systems and health equity.