Patient satisfaction: A feature of quality metrics within the inpatient healthcare system – A narrative review

ABSTRACT

Introduction:

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey reports patients’ perceptions of hospital care. Analyzing results from HCAHPS surveys has been instrumental in assessing and improving patient perceptions of this care. The interactions primary care physicians have with patients in the hospital setting can have a direct impact on this score. While isolated studies have reviewed specific areas that may affect HCAHPS outcomes, we aimed to compile the existing literature from the past five years.

Methods:

EMBASE, PUBMED, and Ovid Medline were searched from each database from 2019 to 2023 to retrieve published data in English language articles addressing interventions to improve patient satisfaction. Main keywords in the manuscripts included: “Patient satisfaction,” “HCAHPS,” “intervention,” “survey,” “database,” “communication,” and “implementation.”

Results:

We deduced seven important factors and interventions that affect HCAHPS scores: 1) Infection prevention protocols negatively impacted patient satisfaction. 2) Geographic allocation of patients did not significantly affect scores. 3) Physician-patient communication was critical in determining patient satisfaction. 4) Training programs, like the acknowledge, introduce, duration, explanation, and thank you approach led to substantial improvements. 5) Addressing language barriers positively impacted satisfaction rates for Limited English Proficient patients. 6) The influence of residents on patient satisfaction varied. 7) Age-related differences in patient care perceptions were observed, with older patients reporting fewer positive experiences, particularly in communication-related measures.

Conclusions:

Several different types of interventions have been beneficial in improving the patient satisfaction scores. Overall, further research is needed to provide further evidence for efficacy of these interventions.

Introduction

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national standardized survey that reports patient’s perceptions of hospital care. HCAHPS began voluntary data collection in 2006 and has established a consistent method for collecting and reporting patient’s perspectives on healthcare, enabling meaningful comparisons across American hospitals.[1,2] In 2008, the United States Department of Health and Human Services introduced the results of the first national survey on patient’s inpatient care experiences, involving nearly 2,600 hospitals. HCAHPS demonstrated that patient surveys can provide standardized data on patient perceptions of their hospital experiences through public reporting of results.[2] The exposure of HCAHPS data aims to inform consumer choices, incentivize quality improvement, and enhance transparency in healthcare quality.[2] The interactions between patients and primary care providers in the hospital setting are one form of influence on these surveys. Isolated studies have reviewed specific areas that may affect HCAHPS and patient outcomes, we aimed to compile the existing literature from the past five years. The aim of this review was to analyze prior literature on HCAHPS responses to delineate factors and interventions that affect HCAHPS scores and subsequent patient satisfaction.

Methods

Since 2006, numerous studies have assessed the impact of several factors and interventions designed to positively influence HCAHPS scores. In this review, our inclusion criteria included the following: any English study in the timeline of 2019-2023 on patient satisfaction or HCAHPS, including review article, meta-analysis, systematic review, original article, and narrative review. We excluded any case report or case series as well as articles prior to 2019, as past research has addressed this data. Any abstracts, editorials, commentaries, and non-medical education papers were also excluded from consideration in our study.

EMBASE, PUBMED, and Ovid Medline were searched from each database inception from 2019 to 2023 to retrieve published data in English language articles addressing interventions to improve patient satisfaction. Main keywords in the manuscripts included: “Patient satisfaction,” “HCAHPS,” “intervention,” “Survey,” “Database,” “Communication,” and “Implementation.” Figure 1 demonstrates the PRISMA diagram of our review.

Figure 1.

PRISMA flow diagram of the studies included and excluded in the review

This narrative review discerned seven important interventions through the impact of several factors, including communication, infection prevention protocols, team structure and geographic allocation of patients on HCAHPS scores. Table 1 summarizes of these studies and results.

Table 1.

Summary of article review findings

Study name, author, year	Study Duration	Number of participants	Intervention/comparison groups	Study findings	Statistical significance
Effect of isolation
Nair et al., 2020	Meta-analysis of 15 studies	Infection prevention (IP) group 3041; non-IP group 28457	Infection prevention vs. no Infection precautions	Patients under the IP protocol gave lower scores regarding respect, communication, assistance, and cleanliness and expressed higher dissatisfaction with care aspects than the control group	N/A
Geographical allocation of patients/Effect of patient’s location in hospital
Siddiqui et al., 2019	Ten years	3012	HCAHPS scores of resident teams’ home clinical units vs. patients assigned to them of their home units over ten years	no significant differences in physician communication, pain management, discharge planning, or nursing communication (48.6% vs 47.5%)	P=0.54
Klein et al., 2022	22 months	1720	An interrupted time series analysis examining patient outcomes before and after the transition to geographic cohorts in 3 inpatient teaching services within a 520-bed academic hospital	Geographic cohort did not significantly affect the length of stay, readmission rates, or HCAHPS scores; HCAHPS scores remained unchanged (77 to 80% top box)	P=0.19
Dawson et al., 2021	21 months	845	Comparison of the HCAHPS scores for patients on medical versus non-medical hospital units	Patients treated on non medicine units had higher overall satisfaction than those on medicine units	P=0.02
Effect of learners on teams
Lappe et al., 2020	Three years	1334 (832 on resident teams vs. 502 on non-academic teams)	HCAHPS score between the academic v/s non-academic services	No differences were observed in the selection of “top box” scores on the HCAHPS	N/A
Walker et al., 2021	12 months	president’s cohort 646 vs. Post resident cohort 487	Introduction of internal medicine resident physicians	The “Recommend” domain on HCAHPS showed a significant improvement in the mean pre-resident to post-resident (57% to 69%)	P=0.0351
Nabeel et al., 2021	4 years	839	Personalized feedback for residents using a patient satisfaction survey	Comparison of pre and post-intervention scores notable for improvements in overall HCAHPS scores (8.52%) (95% CI−0.72 to 17.76)	P=.08
Surani et al., 2023	7 months	1110	Daily computer-generated email that alerted providers to their performance on HCAHPS questions (proportions of “always” responses) along with the performance of their peers and Medicare	The proportion of “always” responses was significantly higher in the intervention group (86% vs 80.5%)	P=0.00001
Communication training interventions
Allenbaugh et al. 2019	7 months	200 pre- and 222 post-HCAHPS surveys	A curriculum for medicine residents and nurses focused on clear communication at the bedside	Increase in communication-specific HCAHPS scores.
Tiperneni et al. 2022	6 months	2507	1) Orientation of house staff, nurses, and attendings on the Acknowledge, Introduce, Duration, Explain, Thank you (AIDET) approach. 2) Implementation of the afternoon rounds (with documentation) along with the morning rounds to summarize the plan and discuss updates throughout the day to enhance doctor-patient communication.	Significant improvement in the communication with doctor domain of the HCAHPS from 8th to 78th percentile	N/A
In-person simultaneous medical interpretation
Quigley et al., 2019	2014–2015	5,480,308 patients	Compared 7 different languages and five ethnic/racial groups	Non-English-preferring patients report worse experiences, particularly in care coordination	N/A
Kosack et al., 2022	2017–2020	Spanish and English-speaking families pre- (n=118) and postimplementation (n=552	In-person, Spanish Equipment-Assisted Simultaneous Medical Interpretation (EASMI)	EASMI significantly improved HCAHPS scores in communication domains and increased medical team and family members’ satisfaction with interpretation, 58% to 95% for Spanish-speaking families, compared to 85% to 83% for English speakers	P=0.001

Results

Effect of isolation

Isolation due to infection prevention (IP) protocols was a factor found to negatively impact patient satisfaction through HCAHPS scores. Nair et al.[3] conducted a meta-analysis which compared the HCAHPS for the patient population with IP (3,041 cases) v/s non-IP (28,457 cases), proving that patients under IP protocol gave lower scores regarding respect, communication, assistance, and cleanliness than the control group. The study emphasizes the importance of patient education as an essential aspect in achieving a harmonious balance between effective IP implementation and positive patient care experiences, ultimately improving HCAHPS scores.

Geographical allocation of patients

Siddiqui et al.[4] conducted a study in 2019 to assess the impact of geographically located care teams on patient satisfaction. This review included 3,012 patients from a four chief staffed internal medicine resident service over ten years, revealing no significant differences in physician communication, pain management, discharge planning, or nursing communication.[4] Geographical impact was studied in 2022 by Klein et al.[5] at a tertiary care hospital in Philadelphia.[5] They found that geographic cohort did not significantly affect length of stay, readmission rates, or HCAHPS scores. Finally, a 2021 study by Dawson et al.[6] compared HCAHPS scores for medicine patients on medical versus non-medical hospital units (ie, cardiology, surgery, etc.). The study included the HCAHPS scores of 845 patients. The study found that patients on non-medicine units were more satisfied than those on the medicine floor (P = 0.02).[6]

Effect of learners on teams

In a 2020 by Lappé et al.[7] they sought to evaluate how academic teams are perceived compared to their non-academic counterparts. They compared the HCAHPS score between the academic and non-academic services from 2015 and 2018, revealing that patients perceived the non-academic service as more skilled, providing better information to the patient when compared with the academic service. However, when based solely on the HCAHPS survey results, patient satisfaction was not observed to be any different in the groups, suggesting that the academic team structure does not impact patient satisfaction.[7] Walker and Delzell[8] readdressed the issue again in 2021, concluding that teaching services, including residents and medical students, may have positively influenced patient recommendations of the hospital. This review, conducted over a span of 12 months at a community academic hospital, also included academic and non-academic services. Results showed a 12% improvement (from 57% to 69%, P value 0.0257) in patient satisfaction among the teaching service hospitalist after introduction of resident into their team.[8]

Feedback for learners can also affect HCAHPS outcomes. Nabeel and colleagues found in their study in 2021 that timely, personalized feedback for residents can lead to sustainable enhancements in overall HCAHPS and the doctor communication HCAHPS domain.[9] They also used a patient satisfaction survey to assess the residents with feedback given to both the resident and attending physician within 48 hours. Over 4 years 839 HCAHPS survey questions focusing on attending physicians were compared over four years. When the researchers compared pre and post-intervention scores, the study revealed notable improvements in overall HCAHPS scores (8.52%) and doctor’s communication scores (6.06%), with increases in courtesy and respect (6.18%), listening (3.12%), and explanation (8.23%).[9] A similar study was conducted by Surani et al.[10] in 2023 on 1110 patients used daily computer-generated email to alert internal medicine physicians about their performance on HCAHPS questions along with the performance of their peers and Medicare. They found that the proportion of “always” responses was significantly higher in the intervention group (86% vs 80.5%, P value 0.00001) compared to control group.[10]

1. Communication training interventions

Allenbaugh et al.[11] developed a curriculum in 2019 at the University of Pittsburgh Medical Centre to improve communication and patient satisfaction. The curriculum incorporated didactics sessions, video illustrations, and role play, and evaluated participant’s communication skills using a checklist. Pre- and post-survey analyses were completed by 76 residents and 85 nurses. Both the residents and nurses showed significant improvement in knowledge and attitudes. In addition, HCAHPS scores improved over the study period, suggesting that investing in communication skills training can enhance patient satisfaction and experience.[11] In 2022, Tiperneni et al.[12] revisited a similar issue by introducing the AIDET approach (Acknowledge, Introduce, Duration, Explain, Thank you) and implementing afternoon physician rounds alongside morning rounds for improved communication. The interventions led to significant improvement in the communication with the doctor domain of the HCAHPS from the 8^th percentile to the 78^th percentile.

2. In-person simultaneous medical interpretation

Ensuring clear communication between patients despite language barriers plays a role in patient satisfaction. In 2019 Quigley et al.[13] reported the data of 5,480,308 patients discharged from 4,517 hospitals (2014–2015) of seven different languages and five ethnic/racial groups. They found that non-English-preferring patients generally report worse experiences, particularly in Care Coordination.[13]

In another study conducted by Kosack et al.[14] in 2022, a higher improvement in satisfaction rates with the implementation of in-person simultaneous medical interpretation was found. Results were attributed to reducing communication errors and increased family participation.

With the population of the developed world aging and the burden on healthcare systems increasing over time, the importance of quality care to this age group is also a topic of interest.

Discussion

This review assessed the existing evidence on interventions to improve HCAHPS domains and patient satisfaction. Efforts to compile and summarize the literature to improve HCAHP scores were carried out in 2017 by Davidson et al.[15] The researchers evaluated outcomes in several domains of the HCAHPS survey. They reported significant improvement in HCAHPS scores with domain-focused interventions. They also suggested that more rigorous research is necessary to identify effective and widely applicable interventions for enhancing patient satisfaction measured by HCAHPS surveys.[15] Through our review, we summarized seven themes from the literature and compared our findings to earlier data.

A 2016 study by Mann et al.[16] investigated changes in patient satisfaction with physician communication. Their results showed improvement in overall satisfaction scores, increasing physician communication by 2.8%.[16] This finding emphasizes the importance of primary care providers taking time to educate the patient on goals, plans, and updates in their care. However, it was reported that patient dissatisfaction grows with the involvement of residents.[16] Similar results were reported again in 2019 by Lappe and Iannuzzi.[7,17] More recent findings by Walker and Delzell[8] demonstrated teaching services were favored when a similar issue was readdressed in 2021. Additionally, in a review by Hurwitz 2023 different types of communication were described, highlighting empathetic and non-verbal forms of communication.[18]

To date, we have no data on length of stay impacting HCAHPS scores from the United States. A 2019 study conducted on lung cancer patients, demonstrated that the extended length of stay was associated with lower physician and nurse communication scores and adequate communication during prolonged hospitalizations played a significant role in patient satisfaction.[19]

The findings in our review regarding real-time feedback have been consistent with previous studies. This was demonstrated by Banka et al.[20] in an intervention that targeted internal medicine resident physicians and included education on patient satisfaction, real-time feedback on patient satisfaction scores, monthly recognition, and incentives for high patient satisfaction scores. The intervention led to a significant increase in the percentage of patients responding positively to physician-related HCAHPS questions (8.1% v/s 2.1% in favor of intervention group) and in the percentage of patients who would recommend the hospital to friends and family (increased by 7.1% v/s 1.5% in favor of intervention group).[20] These additions served as a model to improve patient satisfaction, and hospital revenue, and train resident physicians.[20] The link between communication skills and improved HCAHPS scores appears to be strongly linked through not only feedback to learners and patients but also through patient education of IP precautions.

Studies have proven variable findings of the effect of IP on patient satisfaction.

Baubie et al.[21] studied the impact of IP on patient satisfaction. They found that patients expressed apprehension regarding the limited interaction and visibility of healthcare workers, unresolved inquiries, and delayed responses when under contact precautions. The researchers also found that over half of the participants in the study received insufficient or no education about the utilization of IP measures.[21] This factor may have played a role in the Nair study, which demonstrated similar outcomes.[3] A 2015 literature review found that IP for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci in US hospitals resulted in decreased bedside interactions, reduced contact duration, and fewer patient examinations.[22] On the contrary, a review by Vinski et al.[23] highlighted favorable experiences related to utilizing IP measures. In their study, over 80% of patients stated that they were informed about the measures and believed isolation was safe and beneficial. Another study revealed that when the reasoning behind isolation was communicated to the patients, over 80% expressed contentment with treatment in a hospital with isolation precautions in place.[24] Ensuring proper education for both patients about the IP and the importance of the use of personal protective equipment, increasing interaction time between physician and the patient, and regularly inquiring patient about if they feel isolated due to IP, are essential for achieving a balanced integration of IP measures and maintaining optimal patient care ultimately impacting patient satisfaction scores.

Geographical cohorts can benefit large hospital settings where increased distances between patient rooms can challenge providers to provide patient care efficiently. The studies we reviewed from the past five years did not show a meaningful impact on HCAHPS scores. However, prior research has shown interventions may improve outcomes. Bai et al.[25] evaluated in-hospital mortality among 3,243 consecutive admissions. They found that patients admitted to “off-service” wards had higher in-hospital mortality than those admitted to geographically cohort units within a Canadian tertiary care hospital. The adoption of geographic cohorts alleviated the challenges of inpatient rotations by offering a consistent clinical setting and interprofessional team. This, in turn, reduced cognitive load and enabled residents to focus more on patient care rather than navigating variable conditions across different hospital units. Improved communication and workflow efficiency were cited as contributing factors, echoing findings from a prior study by Bryson et al.[26] Additional studies have also found positive impacts of geographical localization, such as improved patient knowledge and satisfaction, better interprofessional communication and safer workplace culture along with provider satisfaction and perceived efficiency and facilitated the introduction of other interventions including interdisciplinary rounds.[5,26,27]

The use of opioids in management is another aspect of patient care that may have an impact on patient satisfaction. Mazurenko et al.[28] investigated the relationship between the receipt of opioids and patient care experiences among nonsurgical hospitalized adults using data from the HCAHPS patient care experience survey linked to medical records from 11 hospitals from 2011 through 2016.[28] They found no significant association between receiving opioids and patient care experience measures. The study suggests that receiving opioids was not strongly linked to patient care experience measures for nonsurgical hospitalized adults.

This literature review was limited by several factors. HCAHPS studies may be described using several terms that were not included in our keywords. The COVID-19 pandemic affected several aspects of health care and overlapped with our review period, potentially affecting HCAHPS score when comparing our findings to earlier literature. Finally, individual studies may have lower value when compared to meta-analyses in this review.

Conclusion

Patient satisfaction has been a topic of interest for decades, with new insight provided utilizing HCACHPS. Interventions including building curriculum to improve health care provider communication, AIDET approach, real-time feedback, introducing real-life interpreters for non-English preferring patients, and addition of learners, have significantly proven to be beneficial in improving the patient satisfaction scores. In contrast, the geographical rounding itself has not proven beneficial in multiple studies. We recommend that further studies need to be done to further improve patient satisfaction.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.