Which Of These Statements Is Correct About The Scope Of Service Level Management (Slm)?

BMJ Qual Saf. Writer manuscript; bachelor in PMC 2018 Jul 1.

Published in final edited form every bit:

PMCID: PMC5290224

NIHMSID: NIHMS814373

INTERVENTIONS TO Meliorate HOSPITAL PATIENT SATISFACTION WITH HEALTHCARE PROVIDERS AND SYSTEMS: A SYSTEMATIC REVIEW

Karina W. Davidson, PhD, MASc,^1, ^two Jonathan A. Shaffer, PhD, MS,^1, ³ Siqin Ye, Md, MS,¹ Louise Falzon,^ane Iheanacho O. Emeruwa, MD, MBA,¹ Kevin Sundquist, BS,^one Ifeoma A. Inneh, MBA, MPH,^two Susan L. Mascitelli, BSN,⁴ Wilhelmina M. Manzano, MA, RN,⁴ David K. Vawdrey, PhD,² and Henry H. Ting, Physician, MBA²

Karina W. Davidson

^oneCenter for Behavioral Cardiovascular Wellness, Department of Medicine, Columbia University Medical College, New York, NY

²Value Institute, New York-Presbyterian Hospital, New York, NY

Jonathan A. Shaffer

¹Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY

³Department of Psychology, University of Colorado Denver, Denver, CO

Siqin Ye

¹Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical College, New York, NY

Louise Falzon

¹Eye for Behavioral Cardiovascular Wellness, Section of Medicine, Columbia Academy Medical Higher, New York, NY

Iheanacho O. Emeruwa

¹Heart for Behavioral Cardiovascular Health, Department of Medicine, Columbia Academy Medical College, New York, NY

Kevin Sundquist

^aneCenter for Behavioral Cardiovascular Health, Department of Medicine, Columbia Academy Medical Higher, New York, NY

Ifeoma A. Inneh

ⁱⁱValue Constitute, New York-Presbyterian Hospital, New York, NY

Susan L. Mascitelli

⁴New York-Presbyterian Hospital, New York, NY

Wilhelmina M. Manzano

^fourNew York-Presbyterian Infirmary, New York, NY

David K. Vawdrey

²Value Institute, New York-Presbyterian Infirmary, New York, NY

Henry H. Ting

²Value Institute, New York-Presbyterian Infirmary, New York, NY

Abstract

Background

Many hospital systems seek to improve patient satisfaction as assessed by the Hospital Consumer Cess of Healthcare Providers and Systems (HCAHPS) surveys. A systematic review of the electric current experimental evidence could inform these efforts and does non yet exist.

Methods

Nosotros conducted a systematic review of the literature by searching electronic databases, including MEDLINE and EMBASE, the half-dozen databases of the Cochrane Library, and grey literature databases. We included studies involving hospital patients with interventions targeting at least ane of the 11 HCAHPS domains, and that met our quality filter score on the 27-item Downs and Black coding scale. We calculated post-hoc power when appropriate.

Results

A total of 59 studies met inclusion criteria, with with 44 of these did non see the quality filter of 50% (average quality rating 27.viii% ± 10.ix%.) Of the 15 studies that met the quality filter (boilerplate quality rating 67.3% ± 10.7%), 8 targeted the Communication with Doctors HCAHPS domain, 6 targeted Overall Hospital Rating, 5 targeted Communication with Nurses, 5 targeted Pain Management, 5 targeted Communication about Medicines, v targeted Recommend the Hospital, iii targeted Quietness of the Hospital Environment, three targeted Cleanliness of the Infirmary Environment, and iii targeted Discharge Information. Significant HCAHPS improvements were reported past 8 interventions, simply their generalizability may be express by narrowly focused patient populations, heterogeneity of approach, and other methodological concerns.

Conclusions

Although there are a few studies that show some comeback in HCAHPS score through various interventions, we conclude that more rigorous research is needed to place effective and generalizable interventions to ameliorate patient satisfaction.

Keywords: Patient satisfaction, Healthcare quality comeback, Wellness services research, Patient-centered care, Quality improvement

BACKROUND

The importance of patient satisfaction has long beingness recognized,¹ and is being increasingly emphasized by health systems including those of the United Kingdoms^two and the The states.³ In the U.s., beginning in 2007, the Centers for Medicare & Medicaid Services (CMS) launched an ambitious programme to require hospitals to report patient satisfaction through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to be eligible for annual Inpatient Prospective Payment Organisation updates.⁴ HCAHPS results across 11 domains are besides publicly reported through the Hospital Compare website (http://world wide web.medicare.gov/hospitalcompare). Starting in 2012, the CMS program for Hospital Value-Based Purchasing also incorporated HCAHPS survey scores to decide global bonus or penalties for Medicare Severity Diagnosis-Related Groups payments.^4,5

The HCAHPS public reporting and inclusion in Value-Based Purchasing have impelled hospitals and clinicians to closely monitor and improve their patient satisfaction and HCAHPS survey scores. Scientifically, much remains unknown regarding the impact of various interventions for improving patient satisfaction, the magnitude of improvement, and in what context improvement efforts are successful. Given the scope of the CMS HCAHPS plan, a better assessment which interventions are effective would exist vital for improving patient satisfaction in diverse healthcare settings.

We conducted a systematic review of all studies that employed experimental designs to amend infirmary patient satisfaction as measured by the HCAHPS survey. As this is a large domain of possible interventions and practices, nosotros focused specifically on hospital inpatients, receiving interventions to improve patient satisfaction, compared to pre-intervention or control group(s), with a goal of improving HCAHPS scores.

MATERIALS AND METHODS

We conducted a systematic review of the literature using formal methods of literature identification, selection of relevant manufactures, data abstraction, and quality cess. Nosotros then assessed the scope and nature of the available enquiry literature.

Searches

The search strategy was developed by one of the authors (LF), an information scientist. We searched electronic databases, including MEDLINE, EMBASE, and the six databases of the Cochrane Library (inception to date of manuscript submission). The MEDLINE search strategy, which formed the basis for the search strategies for the other electronic databases, is shown in Supplementary Appendix A. We likewise searched the following grey literature: Open Gray and NY Academy of Medicine Grayness Literature Report.

Written report inclusion and exclusion criteria

We included studies of inpatients with interventions targeting at to the lowest degree one of the 21 HCAHPS survey items. Only studies that reported one or more HCAHPS measure as an outcome were included. Nosotros excluded articles written in languages other than English language. We restricted eligible studies to those of sufficient quality to permit data extraction and interpretation, every bit described beneath.

At to the lowest degree two reviewers (JAS, SY, IOE) independently screened the titles and abstracts of all of the citations retrieved by the search strategy to identify manufactures potentially meeting the inclusion criteria. When reviewers agreed that an article was eligible or a conclusion regarding eligibility could not be made because of insufficient information, the commodity was retrieved for full-text review. When reviewers disagreed on eligibility, the remaining team members were consulted and disagreements were resolved by consensus.

Information extraction strategy

We developed a data extraction form to: (one) confirm eligibility for full commodity review, (2) record written report characteristics, and (3) abstract relevant information regarding the intervention. Specifically, nosotros abstracted the HCAHPS domain or domains that were targeted by each intervention, the intervention type and clarification, and the report results. HCAHPS scores are typically presented as percentages of patients who respond using the most positive category^{^ane} (i.eastward., "pinnacle-box scores", "Ever" for five HCAHPS domains, "Yes" for Discharge Data, "ix" or "10" for Infirmary Rating, and "Definitely" for Recommend the Infirmary). For example, if a written report reports that a cohort of patients received a score of 75% on the detail "During this hospital stay how often did nurses treat you with courtesy and respect, this finding indicates that 75% of patients responded "E'er" to this item. Percentage "meridian-box" scores for each of the three nursing communication items are so averaged to yield the "top-box" percentage for the HCAHPS Nurse Communication domain. Where possible we nowadays the improvement in "top-box" scores.

Written report quality assessment and quality filter

We used the Downs and Black rating scale to assess the quality of the studies.⁶ This 27-detail checklist assesses studies' reporting of objectives, outcomes, interventions, and findings; external validity; internal validity; and confounding. Given the pre-mail service nature of nigh of the studies and the fact that different cohorts of participants were assessed during the pre- and post- phases, items pertaining to follow-upward of the aforementioned patients were deemed not eligible for inclusion in the quality rating. In addition, every bit about of the retrieved citations were in abstruse form, we could not assess quality for certain items beyond all studies. Equally such, we offer a prorated score percentage. For example, if nosotros could just assess twenty of the 27 items on the checklist for a given study and that study received 10 points, it was assigned a quality rating of 50%. We defined our quality filter every bit having a prorated quality rating of 50% or college, and restricted our final sample to those studies that met this criteria. As few studies presented data that could be submitted to a meta-analytic approach, we performed only a qualitative review of the evidence.

RESULTS

Literature search and review procedure

We identified 548 unique studies in our initial search results. Of these 548, 98 were selected for championship and abstract review, and 59 were determined to be eligible for formal quality rating, as described in a higher place. A total of 15 studies were selected as eligible for final inclusion because they met our criteria for being of sufficient quality for information extraction and estimation (Figure i).

An external file that holds a picture, illustration, etc. Object name is nihms814373f1.jpg

Description of studies

Eligible studies were published betwixt the years 2013 and 2016. The sample size of the 15 eligible studies ranged from 72 to 3021 patients; however, especially for studies in 2016, the sample sizes for the HCAHPS scores were often non reported, as these were ofttimes secondary outcomes. For evaluation of the impact on HCAHPS interventions, 10 studies featured pre-post designs, four were randomized, controlled trials, and one was a prospective, observational study.

Methodological quality

For the fifteen eligible studies, the average prorated score was 67.three% (±10.7%). An additional 18 studies had quality rating between 0 and 24%, and 26 had quality rating betwixt 25% to 50%; the average quality rating of these 44 studies were 27.8% (±10.9%). Few of the eligible studies provided enough information to rate whether adverse clinical events occurred, whether study participants were representative of the unabridged population from which they were fatigued, and the degree of compliance with the interventions. In addition, near studies provided express information regarding whether attempts were fabricated to mask participants or observers to intervention status. Few studies reported characteristics of the study participants, and even fewer reported whether confounding variables were considered in statistical analyses.

Intervention methods

As seen in Table 1, eight studies targeted the Advice with Doctors HCAHPS domain, half-dozen targeted Overall Hospital Rating, 5 targeted Communication with Nurses, 5 targeted Pain Direction, 5 targeted Advice about Medicines, v targeted Recommend the Hospital, 3 targeted Quietness of the Hospital Environment, 3 targeted Cleanliness of the Hospital Environment, and 3 targeted Discharge Information.

Table 1

Description of High Quality Interventions to Improve Infirmary Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains.

Author/Year	Setting	Pattern and Size	Domains Assessed and Descriptions of Intervention
O'Leary 2013¹⁷	Patients admitted to non- pedagogy hospital service at an academic medical centre in Chicago, IL	Pre-mail service design (N=278 pre vs 186 post)	Communication With Doctors, Overall Infirmary Rating: A advice skills training plan for hospitalists. Patients who were discharged from the hospitalist service during the 26 weeks prior to the intervention were compared to those discharged from the hospitalist service during the 22 weeks subsequently the intervention
Wang 2013¹²	Spine surgery patients at an bookish medical center in Pittsburgh, PA	Pre-post design (Due north=273 pre vs 254 after ane^st intervention vs 214 afterward both interventions)	Communication with Nurses, Communication about Medicines, Belch Information: Beginning intervention was a "surgical flying plan" to standardize advice to patients; second intervention used "SmartRoom" technology to provide patients with tailored didactics videos and informed providers of viewing progress. Patients discharged during 3 months prior to interventions were compared to those discharged during 3 months of the first intervention, and then to those discharged during 3 months of both interventions
Amin 2014¹⁹	All patients at an academic medical center in Irvine, CA	Pre-post design (N= 555 pre vs 534 mail service)	Recommend the Hospital: Care management services were changed from a unit-based to a service-based model, to permit better integration with the care team. HCAHPS comparison was between the diffusion period and the mail service-intervention period.
Fornwalt 2014¹³	All patients at a general medical and surgical hospital in Birmingham, AL	Pre-post pattern (N not reported)	Advice with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, Advice near Medicines, Belch Information, Cleanliness of Infirmary Environment, Quietness of Hospital Environment, Overall Hospital Rating, Recommend the Hospital: Patients discharged during 9 months of a programme of using flyers describing to patients the state of the fine art disinfection existence used (a portable UV disinfection system), compared to patients discharged during the prior xxx months
Simons 2014¹⁵	Patients on general internal medicine hospitalist and housestaff services at an bookish medical eye in Chicago, IL	Clustered randomized controlled trial (N=72 control vs 66 intervention)	Advice with Doctors, Overall Infirmary Rating: Randomization was at the unit level. Physicians working on the intervention units received facecards that listed the name and office of attendings, residents, and interns. The facecards were directly delivered to patients by physicians who participated in their care.
Banka 2015⁹	All patients at an academic medical centre in Los Angeles, CA	Pre-post design (N=465 pre vs 528 post)	Communication with Doctors, Recommend the Infirmary: Patient satisfaction education was provided to internal medicine residents via a conference, real-time feedback, monthly recognition, and a pocket-size reward. Patients discharged post- intervention were compared to those discharged pre-intervention, controlling for changes in satisfaction score for not-internal medicine patients
Chan 2015¹⁸	Patients at a condom internet hospital in San Francisco, CA	Randomized, controlled trial (N=685 full; per arm not reported)	Communication with Nurses, Communication with Doctors, Communication nigh Medicines, Belch Information: Patients randomized to intervention with ane) inpatient visits by a linguistic communication cyclopedia nurse that provided post-hospitalization education and with ii) post-belch phone telephone call by nurse practitioner were compared to patients who received usual care
Harper 2015^vii	Patients undergoing unilateral hip or knee replacement at a single center in Boston, MA	Randomized, controlled trial (Northward=36 in each arm)	Communication with Nurses, Cleanliness of Hospital Environment, Quietness of Hospital Environment, Hurting Management, Overall Infirmary Rating, Recommend the Hospital: Patients randomized to receive animal-assisted therapy (therapy dogs) compared to patients who did not
Indovina 2015¹⁶	Patients on general internal medicine service at a university-affiliated public safety cyberspace hospital in Denver, CO	Randomized, controlled trial (North=35 control vs thirty intervention)	Communication with Doctors, Overall Hospital Rating: Patients were surveyed daily regarding physician communication. Attending hospitalist caring for patients randomized to the intervention arm received daily feedback of survey results, every bit well as brief i-on-1 education and coaching sessions. They were also asked to revisits patients who did give a top box score.
Siddiqui 2015⁸	All patients at an academic medical center in Baltimore, MD	Pre-post pattern with concurrent controls (Due north=1648 pre vs 1373 mail)	Cleanliness of Infirmary Environment, Quietness of Infirmary Environment, Communication with Nurses, Communication with Doctors, Hurting Management, Communication about Medicines, Overall Infirmary Rating, Recommend the Hospital: Patients discharged from a new clinical building during the first seven.5 months, compared to patients on the aforementioned units discharged from the old clinical building during the preceding 12 months
Boissy 2016¹¹	All patients at an academic medical eye in Cleveland, OH	Observational study with command group (N=230 control vs 204 intervention)	Communication with Doctors: All attending physicians were offered eight hours of experiential communication skill training. Those who participated were compared with those who didn't with regards to how they were evaluated by their patients.
Schroeder 2016²⁰	Patients on an orthopedic unit at a community hospital in Johnstown, PA	Pre-mail service design (N not reported)	Pain Direction: Adult online learning module for improving pain assessment for postoperative total joint patients. Module was used to educate nursing staff on orthopedics unit.
Soric 2016¹⁰	Patients on general internal medicine service at a community hospital in Chardon, OH	Pre-post design (N not reported)	Communication about Medicines: Intervention consists of chemist's team (clinical pharmacists, pharmacy resident, and chemist's shop student) participating in team rounds and providing patient education. Comparison was between patients hospitalized prior to the intervention period to those hospitalized later on, though not all patients received intervention.
Titsworth 2016^fourteen	Patients on neurosurgery service at an bookish medical eye in Gainesville, FL	Pre-post pattern (Due north not reported)	Hurting Management: Interdisciplinary team adult and implemented standard analgesia protocol for neurosurgery patients.
Phatak 2016²¹	Patients on general internal medicine services at an bookish medical center in Chicago, NY	Pre-post design (Due north non reported)	Communication about Medicines: Pharmacist intervention for transition of intendance, including face-to- confront medication reconciliation, patient-specific pharmaceutical intendance programme, discharge counseling, and follow-up phone calls.

Efficacy of interventions

Eligible interventions are presented with their quality rating and chief results in Table ii. Eight studies reported statistically significant results. Ane of these was a small randomized, controlled trial, finding that the utilize of therapy dogs prior to physical therapy sessions for orthopedic patients improved Pain Management, Advice with Nurses, and Overall Hospital Rating.⁷ Two studies with pre-post cess plant that constructing a new infirmary building improved Cleanliness of Infirmary Surroundings but did not impact other domains⁸ and that doctor education and real-fourth dimension feedback of patient satisfaction via an information technology intervention improved Advice with Doctors and Recommend the Hospital domains.⁹ Another pre-post assessment of a pharmacy team intervention found pregnant improvement for Communication about Medicine domain,¹⁰ while an observational study assessing an intervention consisting of communication training for attention physicians found improvement in a unmarried item of Communication with Doctors.¹¹. A more complicated study assessed ii sequential interventions using a "surgical flight plan", and so providing a large menu of patient education videos via "SmartRoom" engineering.¹² Although this latter study reported some statistically significant improvements in individual communication questions from different domains, this was afterward multiple comparisons without correction, and domain scores were not reported. An additional study reported the results of advertising nearly the use and cleanliness of a portable ultraviolet (UV) disinfection device.^xiii Although the authors reported improvement in the Cleanliness of Hospital Environment domain, the sample size was not reported, and there was already a strong trend for improvement for many HCAHPS domains even prior to the intervention. Similarly, a final report on development and implementation of a standardized analgesia protocol for neurosurgery patients demonstrated comeback in Pain Management, only the authors state that persistent trends in improvement later on the intervention argues for the presence of other system causes for the observed improvement.¹⁴

Table 2

Results of high quality interventions on Better Hospital Consumer Cess of Healthcare Providers and Systems (HCAHPS) domain scores. Number needed (number in study) are calculated for domain composite scores and not for individual survey items.

Writer / Twelvemonth	Downs & Black Quality Rating	Results
O'Leary 2013¹⁷	81%	Communication with Doctors: Blended score: Pre: 75.8% vs Postal service: 79.2%, p = 0.42 Doctors treated with courtesy/respect: OR for top-box rating with intervention = 1.23 (0.81–2.44), p = .22 Doctors listened: OR = 1.22 (0.74–ii.04), p = 0.42 Doctors explained: OR = 0.98 (0.59 –ane.64), p = 0.94 Overall Hospital Rating: OR for overall rating of nine or x = ane.33 (0.82–ii.17), p = 0.24
Wang 2013¹²	67%	Advice with Nurses: Nurse explained things in a style you could understand: 72% (both interventions) versus 58% (pre-intervention), p = 0.027 Communication about Medicines: Staff tell y'all what new medicine was for: 81% (both interventions) versus 64% (one^st intervention only), p = 0.029 All other comparisons not-significant
Amin 2014^xix	55%	Recommend the Hospital: Pre: 78.9% vs Mail: 77.eight%, p = 0.267
Fornwalt 2014¹³	62%	Cleanliness of Hospital Environment: Pre: 48% to 77.5% vs Mail: 83%, p = 0.022
Simons 2014¹⁵	59%	Communication with Doc: Composite score: 63.half-dozen% (Intervention) versus 54.2% (Control), p = 0.26 Overall Hospital Rating: Composite score: 70.eight% (Intervention) versus lxx.8% (Command), p = 0.99
Banka 2015⁹	76%	Communication with Doctors: Composite score is modify in the intervention units minus the alter in the control units= half dozen.vi%, p = 0.04 Doctors always treated with courtesy and respect: mail minus pre = 4.ane%, p = 0.09 Doctors always listened advisedly: post minus pre = 4.vi%, p = 0.1 Doctors explained things in way patient could sympathize: post – minus pre = 6.eight%, p = 0.03 Recommend the Hospital: Differential post minus pre =5.vi%, p = 0.02
Chan 2015¹⁸	60%	Advice with Nurses: 90 (Intervention) versus 89 (Control), p = 0.35 Advice with Doctors: 91.9 (Intervention) versus 91.eight (Control), p = 0.threescore Advice about Medicines: 72.3 (Intervention) versus 75.seven (Control), p = 0.34 Belch Information: 82.9 (Intervention) versus 78 (Control), p = 0.11
Harper 2015⁷	84%	Communication with Nurses: Treatment: 92% (95% CI, 78% – 98%) vs Control: 69% (95% CI, 52% – 84%), p = 0.035 Pain Management: Treatment 94% (95% CI, 81%–99%) vs Control 72% (95% CI, 55% – 86%), p = 0.024 Overall Hospital Rating: Treatment: 9.6 (SD = 0.7) vs Command: 8.6 (SD = 0.9), p < 0.001 Advice with Doctors: Treatment: 81% (95% CI, 64% – 92%) vs. Control: 78% (95% CI, 61% – 90%), p = one.0 Cleanliness of Hospital Environment and Quietness of Hospital Environment: Treatment: l% (95% CI, 34% – 66%) vs. Control: 53% (95% CI, 37% – 69%), p = ane.0 Recommend the Hospital: Treatment: 100% vs Control: 100%, p = 1.0
Indovina 2015¹⁶	seventy%	Advice with Doctors: Doctors treated with courtesy/respect: Intervention: 93% versus Control: 86%, p > 0.05 Doctors listened: Intervention: ninety% versus Control: 83%, p > 0.05 Doctors explained: Intervention: 80% versus Command: 77%, p > 0.05 Overall Hospital Rating: Intervention: fourscore% versus Control: 61%, p > 0.05
Siddiqui 2015^viii	86%	Cleanliness of Hospital Environment: OR for height-box score with intervention = one.62 (1.twoscore–one.90), p = 0.03 Quietness of Hospital Environment: OR = 1.89 (1.63–2.19), p < 0.0001 Advice with Nurses: Nurse treated with courtesy respect: OR = i.28 (one.05–one.57), p =0.92 Nurse listened: OR = i.21 (1.03–ane.43), p = 0.26 Nurse explained: OR = ane.10 (0.94–1.30), p = 0.43 Advice with Doctors: Doctors treated with courtesy/respect: OR = 1.thirteen (0.89–1.42), p = 0.77 Doctors listened: OR = 0.93 (0.83–ane.19), p = 0.68 Doctors explained: OR = 1.00 (0.84–1.xix), p = 0.49 Pain Management: Pain well controlled: OR = 1.06 (0.90–1.25), p = 0.60 Staff do everything to help with pain: OR = 1.19 (0.99–one.44), p = 0.07 Communication about Medicines: Staff describe medicine side furnishings: OR =1.05 (0.89–1.24), p =0.32 Tell you what medicine was for: OR = 1.02 (0.84–1.25), p = 0.65 Overall Infirmary Rating: OR = 1.71 (1.44–ii.05), p = 0.006 Recommend the Hospital: OR = ane.43 (i.18–one.76), p = 0.03
Boissy 2016¹¹	threescore%	Advice with Doctors: Numbers reported are mean scores (not top box) adjusted for baseline and other co-variables. Doctors treated with courtesy/respect: Intervention: 91.08 versus Control: 88.09, p = 0.02 Doctors listened: Intervention: 83.13 versus Command: 82.79, p = 0.78 Doctors explained: Intervention: Intervention: 77.35 versus Command: 76.38, p = 0.50
Schroeder 2016²⁰	52%	Pain Direction: Pre: 70.2% (standard divergence, 9.five%) versus Mail service: 73.9% (standard divergence, 6.0%), p not reported
Soric 2016¹⁰	57%	Advice most Medicines: Composite top box score: Pre: 52.iv% versus Post: 61.2%, p < 0.001 Staff describe medicine side effects: Pre: 67.8% versus Post: 77.3%, p < 0.001 Tell you what medicine was for: Pre: 39.3% versus Mail: 45.2%, p < 0.001
Titsworth 2016^xiv	71%	Hurting Direction: Pre: 64.3% versus Mail: 72.viii%, p = 0.007; nevertheless, trend persisted well-after intervention, and authors suspect other institutional changes equally reason for improvement.
Phatak 2016²¹	69%	Communication about Medicines: Blended top box score: Pre: 47% versus Post: 56%, p not reported.

Seven boosted studies did not report significant findings, either because statistical significance was non assessed or the written report had inadequate power, or because the interventions were implemented inappropriately or were truly ineffective. Ii randomized controlled trials assessed interventions targeting medico communication, one through providing patients with physician face cards^xv while the other by providing physicians with training and real-time patient satisfaction feedback.¹⁶ Although both demonstrated positive trends, the sample size for which HCAHPS scores were assessed was small, which may have limited their ability to detect statistical significance. Another pre-postal service assessment of a communication skills training program for hospitalists also did not improve Communication with Doctors or Overall Infirmary Rating.¹⁷ A randomized, controlled trial for a nurse-led, language-concordant, hospital-based care transition program that did not improve any of the Communication domains or Discharge Information domains;¹⁸ similarly, a pre-post cess of changing intendance management from a unit-based model to a service-based one did not affect HCAHPS score for Recommend the Hospital.^xix Finally, 2 studies did not report p-values. One involved the development and deployment of a pain direction education module for nurses on an orthopedic unit, showing potential improvement in Pain Management,²⁰ while the other was a personalized chemist intervention for transition of care, with potential improvement in Communication most Medicine.²¹ Both studies used HCAHPS scores for pre-postal service assessment but did not report sample sizes or statistical testing for HCAHPS comparisons.

DISCUSSION

In this systematic review of interventions to better HCAHPS scores, we institute that most of the studies published were of depression quality. For those with satisfactory quality, the well-nigh frequent HCAHPS domains targeted included Communication with Doctors, Communications with Nurses, Advice nearly Medicines, Hurting Management, Recommend the Hospital, and Overall Infirmary Rating. These studies differed widely in approach, methodology, and targeted patient population, and even the studies that reported statistically significant results often have caveats that would limit recommendations for adapting them at other healthcare institutions.

Our results also highlight the dilemma faced by health care institutions that seek to improve HCAHPS scores, as it is unclear whether comprehensive approaches such equally global doctor education or new facilities would be more effective, or if it might better to target specific units or HCAHPS domains. Our review identified remarkably few loftier-quality designs and/or evaluations, with nearly demonstrating bear upon that was narrow in scope and modest in magnitude. Beyond the heterogeneous domains assessed through the HCAHPS survey, we found little show of either specific or globally efficacious interventions for the HCAHPS domains. Well-nigh all of the studies located were of poor methodological quality and simply a few employed a rigorous intervention design, and it is often unclear whether the effect on HCAHPS scores is the directly result of the intervention or is due to spill-over effects. Thus, any type of quantitative synthesis to estimate effect sizes was not possible. Nosotros did find that of those that were eligible by our quality filter a slight majority had significant findings. However, caution is warranted in interpreting fifty-fifty these results, as frequently the reported HCAHPS scores are secondary outcomes collected through the mandated surveys, and, as several authors acknowledge, could be influenced by other ongoing quality initiatives.

The lack of advisable design, reporting, and statistics amidst our additional 44 located but quality-ineligible studies is problematic for the comeback of patient satisfaction with hospital and provider care for many reasons. Start, in that location may be important and useful hospital/provider improvements that were tested amongst these possible interventions that will go unrecognized, because studies did not have sufficient sample sizes or robust written report designs to assess their usefulness. Second, hospital and clinician initiatives, such as interdisciplinary rounding and commercial client service training, are currently beingness implemented and disseminated by hospitals at great expense, but at that place is niggling published evidence suggesting these will result in improvements in patient satisfaction, particularly across diverse geographic and practice contexts. The absence of high-quality evidence about ways to improve the hospital experience for patients leaves healthcare leaders with petty more anecdotes to guide their strategic determination-making. For example, ane healthcare leader conducted daily CEO rounds,²² but information technology is not articulate how beneficial this type of practice might be considering anecdotal/single case studies are the only available evidence. In the absence of rigorous, actionable evidence on which to estimate the appropriateness of interventions aimed at improving patient satisfaction, nosotros cannot look hospitals or clinicians to adopt best evidence-based practices.²³

To assistance accost these issues, information technology would be useful for future studies to adapt more than rigorous approaches. These would include formal power calculations that take into business relationship reasonable assumptions for effect size and local survey response rate. The latter is particularly important, as in our experience it is often no longer feasible to directly acquit surveys using HCAHPS items as part of written report protocols, due to concern for contamination with CMS required surveys. This likely explains our ascertainment that more contempo studies accept tended to use HCAHPS scores obtained through surveys as secondary outcomes. An example of such a power calculation might exist as follows. If a hospital had a response rate of 35%, and wanted to improve one of the HCAHPs domains from their electric current 75% to fourscore%, it would take approximately 2,262 survey responses to effectively test their proposed intervention; 6,463 patients would demand to be exposed to the intervention to receive that many surveys. More thoughtful sample size planning in this way might alleviate the issue of being unable to assess whether a targeted intervention that met the principal research outcomes might besides meaningfully impact patient satisfaction as measured by the HCAHPS score.

One of the reasons for the excitement and involvement in improving patient satisfaction with hospital care is derived from other report results that have noted that these scores are observationally associated with improved clinical outcomes.^24–28 A recent systematic review ended that higher patient satisfaction was observationally associated with better patient safety, clinical effectiveness, health outcomes, adherence, and lower resource utilization.²⁹ Even so, many other studies examining quality procedure measures, such as those reported by the Infirmary Compare website, take found a depression concordance betwixt excellence in intendance and HCAHPS scores (kappa < 0.20).^thirty

Yet other studies have constitute no association between patient satisfaction and the technical quality of care.³¹ A national study of 51,946 adult respondents reported that higher patient satisfaction was associated with higher risk of inpatient admission, greater expenditures, greater prescription drug expenditures and college mortality;³² and a study of 31 hospitals in 10 states reported that patient satisfaction was contained of infirmary compliance with surgical processes of quality care.³³ All the same, despite some inconsistencies, patient satisfaction is likely to remain a key quality metric, particularly given its essential importance to the relationship between patients and the healthcare system.³⁴ It is therefore imperative to identify effective patient satisfaction interventions, and to straight investigate if improving patient satisfaction tin likewise directly meliorate other of import clinical outcomes.

This systematic review does have implications for policy and for public reporting. As of now, at that place is a lack of bear witness-based interventions for improving HCAHPS scores, yet hospitals are being driven, through value-based purchasing and public reporting, to use a metric that may non be easily modifiable. The majority of hospitals that currently have high HCAHPS scores are small (< 200 beds), and are based in a customs setting. If receiving care at an urban hospital necessarily results in lower patient satisfaction – perhaps because of factors such as crowded facilities, clinical or sociodemographic case mix, and payer mix – penalizing those hospitals serving those with the greatest needs seems counterproductive to the ultimate goals of the CMS and Affordable Care Act (ACA) programs. Further, adjustment for sociodemographic variables at the hospital level may improve comparisons of patient satisfaction between hospitals and reduce the unintended consequences of value-based purchasing penalties. To finer ameliorate patient satisfaction, we demand to discover modifiable causes for patient dissatisfaction that are empirically tested with advisable designs and sufficient statistical power in similar types of hospitals. But and so tin can nosotros test if this improves, or harms, the quality of care received past a patient.

What then can be done to move this field forward? At that place seem to exist few interventions either designed to improve 1 patient satisfaction domain, beyond all hospitalized patients, and that is rigorously tested for usefulness. These might be the side by side generation of interventions, which if married with more than rigorous designs and power analyses, appropriate correction for multiple comparisons, and use of the correct unit of measurement of analysis (e.one thousand. site, physician, patient, service line) would be helpful in edifice an testify-base. Published interventions nigh normally used a pre-postal service pattern, which does not guard against secular trends, contamination by other co-occurring interventions, and the other validity threats present when randomization is not present. An instance of future useful intervention might exist randomizing all physicians to either receive or not receive existent-time feedback on their own Advice with Doctors domain scores, to decide if this improved that one domain beyond the hospital, and beyond all patient groups. Or, one could exam 1 of many behavioral economic science approaches take been used to change physician behavior, including randomizing physicians to a peer-commitment alphabetic character virtually their Communication with Doctors score goal, vs no such commitment.³⁵ Some other case might be implementing sleep hygiene environment practices for all patients on a floor,³⁶ in which noise meters, red-spectrum lighting, and white noise machines are introduced, and alerts, overhead paging systems and elective phlebotomy are minimized or eliminated. Units could exist randomized in a stepped wedge design to test the rollout of such environmental changes to determine if the Cleanliness of Hospital Environment and Quietness of Hospital Environment domains are improved. Guarding against multiple comparisons and conducting the analyses mindful of the correct unit of assay (surveys nested within physician, or within unit) would be of import. Successful studies forth these lines would also need to recognize resource constraints and the operational priorities of healthcare systems. Thus, these types of innovative interventions will require close collaboration amidst hospital leadership with front-line staff and patients, to address the need for the comeback in satisfaction with health intendance service, while rigorously testing the implications of the intervention for the quality of that care.

Limitations

The systematic review reported here is express by a number of factors. Kickoff, because the HCAHPS score contains many domains, this required the use of a broad range of search terms which contributed to the heterogeneity of the studies captured. Relatedly, this "scoping review" differed from an in-depth systematic review in that: (one) paw searching was not conducted, (ii) there was no contact with the written report authors, and (iii) there was no attempt to combine results in a meta-assay.³⁷

CONCLUSION

In conclusion, nosotros identified few high-quality studies that tested the efficacy of interventions to improve patient satisfaction scores as assessed by the HCAHPS survey. Despite the visibility of public reporting and accountability of value-based purchasing for HCAHPS survey scores, there is minimal evidence to inform hospitals, clinicians, payers, and healthcare policy/management experts about what interventions can better patient satisfaction and in what context. Given the importance of patient satisfaction as well as patient outcomes, safety, and cost in loftier-value healthcare, there is an urgent need for properly designed interventions to evaluate novel and sustainable methods to better patient satisfaction, that accept a demonstrable bear on on important clinical outcomes, and that can be spread across dissimilar regions and hospital contexts.

Supplementary Material

Appendix A

Acknowledgments

Dr. Davidson is a member of the U.s.a. Preventive Services Task Strength (USPSTF). This commodity does non necessarily represent the views and policies of the USPSTF. Dr. Davidson is besides the co-owner of MJBK, Inc., a small business that provides mhealth technology solutions to consumers. She is too the co-owner of IOHealthWorks, LLC., a minor consulting services company.

Dr. Ting is a member of the National Quality Forum Consensus Standards Blessing Committee and the American Board of Internal Medicine Council.

This piece of work was supported by the Value Institute of New York Presbyterian Hospital, and New York State Department's Empire Clinical Research Investigator Program (ECRIP). Additional support was provided by contract #ME-1403-12304 of the Patient-Centered Outcomes Research Institute. Drs. Shaffer and Ye are supported by National Institutes of Health K23 career evolution awards (K23 HL112850 and K23 HL121144, respectively).

Abbreviations

HCAHPS	Hospital Consumer Assessment of Healthcare Providers and Systems
CMS	Centers for Medicare & Medicaid Service
PICO	problem/patients intervention comparison outcomes
QI	quality improvement
ACA	Affordable Intendance Act

Footnotes

¹HCAHPS items are scaled in a number of different ways. Fourteen items feature a four point response scale ranging from "Never" to "Always." 3 items utilise a four point response scale ranging from "Strongly Disagree to Strongly Agree." Ii discharge-related items offer a yep/no response pick. Overall rating of intendance uses an 11-bespeak Likert scale, and the item "Likelihood to recommend" features a iv-point response scale ranging from "Definitely No" to "Definitely Yes."

Competing interests

Dr. Davidson has disclosed those interests fully to Columbia Academy Medical Heart, and has in place an approved programme for managing any potential conflicts arising from this organization.

Authors' contributions

JAS, SY, KS, IAI, and IOE conducted the title, abstract, and full text review for this written report, performed information extraction, evaluated study quality, and drafted major parts of the manuscript. LF adult the search strategy. DKV, SLM, WMM, HHT, KWD, JAS, and SY conceived the idea for this written report, and drafted major parts of the manuscript. All authors read and approved the final manuscript.

References

one. Cleary PD, McNeil BJ. Patient Satisfaction as an Indicator of Quality Care. Inquiry. 1988;25(1):25–36. [PubMed] [Google Scholar]

two. Roland M. Linking physicians' pay to the quality of intendance--a major experiment in the Britain. The New England journal of medicine. 2004;351(14):1448–1454. [PubMed] [Google Scholar]

iii. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Xx-First Century. Washington DC: The National Academies Press; 2001. [Google Scholar]

six. Downs SH, Blackness N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Customs Health. 1998;52(6):377–384. [PMC free article] [PubMed] [Google Scholar]

7. Harper CM, Dong Y, Thornhill TS, et al. Tin therapy dogs better pain and satisfaction afterwards total articulation arthroplasty? A randomized controlled trial. Clin Orthop. 2015;473(1):372–379. [PMC gratis article] [PubMed] [Google Scholar]

8. Siddiqui ZK, Zuccarelli R, Durkin N, et al. Changes in patient satisfaction related to infirmary renovation: experience with a new clinical edifice. J Hosp Med. 2015;10(three):165–171. [PubMed] [Google Scholar]

nine. Banka K, Edgington S, Kyulo N, et al. Improving patient satisfaction through physician education, feedback, and incentives. J Hosp Med. 2015;10(8):497–502. [PubMed] [Google Scholar]

10. Soric MM, Glowczewski JE, Lerman RM. Economic and patient satisfaction outcomes of a layered learning model in a small community hospital. Am J Health-Syst Pharm. 2016;73(seven):456–462. [PubMed] [Google Scholar]

11. Boissy A, Windover AK, Bokar D, et al. Communication Skills Preparation for Physicians Improves Patient Satisfaction. Journal of general internal medicine. 2016 [PMC free article] [PubMed] [Google Scholar]

12. Wang W, Dudjak LA, Larue EM, et al. The influence of goal setting and SmartRoom patient instruction videos on readmission rate, length of stay, and patient satisfaction in the orthopedic spine population. Comput Inform Nurs. 2013;31(9):450–456. [PubMed] [Google Scholar]

thirteen. Fornwalt 50, Riddell B. Implementation of innovative pulsed xenon ultraviolet (PX-UV) environmental cleaning in an acute care infirmary. Gamble manag. 2014;7:25–28. [PMC gratis commodity] [PubMed] [Google Scholar]

fourteen. Titsworth WL, Abram J, Guin P, et al. A prospective time-series quality comeback trial of a standardized analgesia protocol to reduce postoperative pain amongst neurosurgery patients. Journal of neurosurgery. 2016:i–10. [PubMed] [Google Scholar]

fifteen. Simons Y, Caprio T, Furiasse N, et al. The touch on of facecards on patients' knowledge, satisfaction, trust, and understanding with infirmary physicians: a pilot study. Journal of Hospital Medicine (Online) 2014;9(3):137–141. [PubMed] [Google Scholar]

16. Indovina Yard, Keniston A, Reid M, et al. Existent-time patient experience surveys of hospitalized medical patients. Journal of infirmary medicine : an official publication of the Society of Infirmary Medicine. 2016 [Google Scholar]

17. O'Leary KJ, Darling TA, Rauworth J, et al. Bear on of hospitalist communication-skills training on patient-satisfaction scores. J Hosp Med. 2013;8(vi):315–320. [PubMed] [Google Scholar]

18. Chan B, Goldman LE, Sarkar U, et al. The Issue of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial. J Gen Intern Med. 2015 [PMC complimentary article] [PubMed] [Google Scholar]

19. Amin AN, Hofmann H, Owen MM, et al. Reduce readmissions with service-based care management. Prof Instance Manag. 2014;19(6):255–262. [PubMed] [Google Scholar]

20. Schroeder DL, Hoffman LA, Fioravanti Grand, et al. Enhancing Nurses' Pain Assessment to Ameliorate Patient Satisfaction. Orthop Nurs. 2016;35(2):108–117. [PubMed] [Google Scholar]

21. Phatak A, Prusi R, Ward B, et al. Touch on of chemist involvement in the transitional care of loftier-risk patients through medication reconciliation, medication pedagogy, and postdischarge phone call-backs (IPITCH Study) Journal of hospital medicine : an official publication of the Lodge of Hospital Medicine. 2016;eleven(one):39–44. [PubMed] [Google Scholar]

23. Lewis S. Toward a general theory of indifference to research-based bear witness. J Wellness Serv Res Policy. 2007;12(3):166–172. [PubMed] [Google Scholar]

24. Jha AK, Orav EJ, Zheng J, et al. Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(xviii):1921–1931. [PubMed] [Google Scholar]

25. Glickman SW, Boulding Westward, Manary M, et al. Patient satisfaction and its relationship with clinical quality and inpatient bloodshed in acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;iii(2):188–195. [PubMed] [Google Scholar]

26. Anhang Price R, Elliott MN, Zaslavsky AM, et al. Examining the Role of Patient Experience Surveys in Measuring Health Care Quality. Med Care Res Rev. 2014;71(5):522–554. [PMC free article] [PubMed] [Google Scholar]

27. Glickman SW, Boulding W, Manary M, et al. Patient Satisfaction and Its Human relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction. Circulation: Cardiovascular Quality and Outcomes. 2010;3(2):188–195. [PubMed] [Google Scholar]

28. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in The states hospitals. Annals of surgery. 2015;261(1):ii–8. [PMC free article] [PubMed] [Google Scholar]

29. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1):e001570. [PMC free article] [PubMed] [Google Scholar]

xxx. Girotra Due south, Cram P, Popescu I. Patient Satisfaction at America's Lowest Performing Hospitals. Circulation: Cardiovascular Quality and Outcomes. 2012;5(3):365–372. [PMC complimentary article] [PubMed] [Google Scholar]

31. Chang JT, Hays RD, Shekelle PG, et al. Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care. Ann Intern Med. 2006;144(nine):665–672. [PubMed] [Google Scholar]

32. Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405–411. [PubMed] [Google Scholar]

33. Lyu H, Wick EC, Housman M, et al. Patient satisfaction as a possible indicator of quality surgical care. JAMA surgery. 2013;148(iv):362–367. [PubMed] [Google Scholar]

34. Chatterjee P, Tsai TC, Jha AK. Delivering value by focusing on patient experience. The American periodical of managed care. 2015;21(10):735–737. [PubMed] [Google Scholar]

35. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA internal medicine. 2014;174(3):425–431. [PMC free article] [PubMed] [Google Scholar]

36. Koch S, Haesler E, Tiziani A, et al. Effectiveness of sleep management strategies for residents of aged care facilities: findings of a systematic review. J Clin Nurs. 2006;15(ten):1267–1275. [PubMed] [Google Scholar]

37. Borkhoff CM, Wieland ML, Myasoedova Due east, et al. Reaching those most in need: a scoping review of interventions to better wellness care quality for disadvantaged populations with osteoarthritis. Arthritis Care Res (Hoboken) 2011;63(i):39–52. [PubMed] [Google Scholar]