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A PATIENT SATISFACTION SURVEY OF
THE MASSACHUSETTS GENERAL HOSPITAL CANCER CENTER
A Capstone Seminar Paper for
HSA 596 Seminar in Health Services Administration
Presented to Dr. Robert Guerrin
Department of Health Service
Administration
Russell Sage College
In Partial Fulfillment of
the Requirements for the Degree of
Master of Science in Health Services Administration
by
Mark A. Campoli
May 1995
TABLE OF CONTENTS
I. PROBLEM STATEMENT................................................3
II. LITERATURE REVIEW..................................................5
III. METHOD.......................................................................14
IV. RESULTS.......................................................................18
V. DISCUSSION.................................................................31
VI. REFERENCES................................................................34
VII. APPENDIX.....................................................................37
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PROBLEM STATEMENT
Quality of patient care has become a central topic as the nation and the health care
industry reevaluate the service delivery system. It has become increasingly clear that the
health care system has evolved into an unwieldy and expensive entity. All aspects of
health care are being examined in an attempt to develop a more efficient and effective
delivery system. Due to survival concerns of hospitals and health care plans in this time
of upheaval, more emphasis is being placed on patient-centered care as a means of
directly addressing treatment efficiency and efficacy. Implementing patient centered care
means:
assessing patient perceptions of the organization and of the
coordination of their care;
respect for their values, preferences, and needs;
the provision of information about their illness and treatment
procedures and how their lives will be affected;
the addressing of physical comfort, emotional support, and involvement
of significant others;
and the quality of the interpersonal aspects of their care.
Patient satisfaction is one component of the measurement of the patient-centered view of
quality of care. This study will focus on the assessment of patients' overall satisfaction
and satisfaction with the interpersonal aspects of their care. A recent survey published in
Health Communication found that patients placed a high value on interpersonal
communication and relationships where concern was demonstrated were highly regarded.
From the patient's perspective, the interpersonal treatment forms a more lasting
impression of the healthcare agency than do the clinical and technical aspects of care
(Ruben, 1993).
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The Cancer Center at the Massachusetts General Hospital (MGH) is a
comprehensive and multifaceted cancer treatment center providing services of
assessment, diagnosis, education, support, treatment and follow-up. An interim
evaluation of service delivery at the Center was recently completed by the MGH Cancer
Center Patient Focus Team. The team's mission is to develop a system of care for cancer
patients and their families that is specifically focused on and responsive to patients'
needs. All aspects of care are to be designed "through the eyes, ears, thoughts and
emotion of the patient" (Cancer Center Patient Focus Team Interim Report, 1994). As a
result of this mission, the evaluation was based on patient focus group results and
covered a range of topics including accessibility, patient and family support, coordination
of care, education, environment, and interpersonal aspects. The report recommended
several clinical and non-clinical initiatives. These initiatives are seen as essential to
uphold MGH's world class quality during times of unprecedented turbulence in health
care. One of the initiatives from the Patient Focus Team Interim Report is to maintain
and communicate the patients' perspective by periodically soliciting patient feedback.
This study attempts to evaluate this initiative by examining one MGH clinical cancer
service and assess patient satisfaction directly from patient reports. The results will be
used to determine existing strengths and to generate recommendations for improvement.
It is also hoped this study may serve as a model for further evaluation of the delivery of
care in a specific and useful manner. In addition to describing patient satisfaction with
the interpersonal aspects of the service delivered by the clinic in question, demographic
variables will be examined to help assess the extent to which variations in the reported
quality of care might be attributed to certain patient characteristics.
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LITERATURE REVIEW
Background of the Problem
Quality of care and patient satisfaction.
In the 1970's, the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) defined quality as "the degree of adherence to generally recognized
contemporary standards of good practice and achievement of anticipated outcomes for a
particular service, procedure, diagnosis or clinical problem" (Appel, 1991). This
description of quality speaks to the need for standards and measures but does not include
the concept of using input from the recipient of care. To many health care professionals,
the most visible result of the commission's agenda for change has been the inspection and
testing of clinical indicators as measures of the quality of medical care. Although clinical
treatment measurements are important, there are other activities underway that are likely
to have a far more reaching impact for health care providers (Appel, 1991). The JCAHO
is using the mechanism of standards revision to lead healthcare organizations into a
transition to Continuous Quality Improvement (CQI). The new set of leadership
standards has appeared in the Accreditation Manual for Hospitals (AMH: JCAHO, 1994).
The AMH articulates an application of W. Edwards Demings 14-point program for
Continuous Quality Improvement as it relates to health care. Demings is best known for
having helped Japanese industry rebuild its economy after World War II. However, he is
relatively unknown in American industry and practically unknown to the U.S. health care
environment (Neuhauser, 1990). The special application of Demings' points compiled by
the JCAHO identify quality as a survival issue. The commitment to CQI translates into
better service for the patient and the community. It further states that healthcare should
cease dependence on inspection to achieve quality. Rather, the focus should be
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shifting from quality by inspection to quality by consumer or patient satisfaction
(Michigan Hospitals, 1991).
In striving to arrive at a more functional description of quality using CQI
concepts, the Task Force for Quality Management for Health Care Delivery states that
quality may be described within the following context: " a healthcare delivery system is a
series of interlinked processes, each of which results in one or more outputs. Quality
represents an individual's subjective evaluation of an output and the personal interactions
that take place as the output is delivered to the individual" (QMMP, 1989).
The Health Security Act of 1993 was created to set standards and guidelines for
health professionals, reorient quality assurance programs to measure outcomes rather
than to blindly promulgate regulations, increase the national commitment to medical
research, and promote primary and preventative care. The Health Security Act guarantees
that the pursuit of six fundamental principles will be emphasized and that they are not
negotiable. These principles include the guarantee of benefits to all, cost containment,
enhancement of quality, access to care, reduction of paperwork, and increase in
responsibility for individual health. The third of these principles is the enhancement of
quality of care: to make the world's best care better. The purpose of this principle is to
protect and enhance of the quality of patient care. Within the principle of enhancing
quality, one of the eight clearly stated objectives for implementation requires that regular
surveys of consumer satisfaction be used to measure health plans. Consumers will receive
"quality report cards" that request information on the performance of health care plans
and patient satisfaction. These report cards will hold plans accountable for meeting high
standards. The National Quality Program will help states share information on health
plan performance as they revamp their health care delivery systems (The White House,
1993).
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In addition to being of primary interest to regulators, patient satisfaction is of
great interest to health care researchers. Patient satisfaction is widely used as a dependent
variable to evaluate medical care and has been identified by the National Center for
Health Services Research and Health Care Technology Assessment as one of the three
major categories of criteria for evaluation of health care systems (Lewis, Scott, Pantell,
& Wolf, 1986). The rationale for making subjective assessments of patient care part of
quality assurance was articulated by Donabedian (1980), who identified patient
satisfaction as a factor directly influencing compliance with medical regimens and
decisions regarding continuity and access to care. Increasingly, proper evaluation of
patient satisfaction is of primary importance to health care providers, insurers, and
patients. Hospitals need to examine the way they collect data and the type of satisfaction
data gathered. Patient satisfaction survey instruments must provide specific information
on what patients need, not only general ratings of satisfaction. David Gustafson, PhD,
from the University of Wisconsin Hospitals states, "The typical patient satisfaction
survey that simply asks, 'How do you like our doctors, nurses, our cafeteria food,' doesn't
get at customer needs at all" (Koska, 1992). Specific criteria about the relationship of
need and the type of service provided, must be established. This must then be followed
by baseline monitoring of how well needs are being met. Improvements can be charted
that meet the goals of quality assurance or CQI (Koska, 1992).
The demand for quality care is not only coming from regulators, but also from
purchasers of managed care and patients. Quality will no longer be assumed present
merely because of a written report or charted record of outcome. Purchasers and
consumers alike are demanding high value for dollars spent (Edford, 1990). Patient-
consumers are demanding more information on health costs, utilization patterns, and
outcomes. There is growing consensus that monitoring quality of care should be based, at
least in part, on patients' perceptions (Boscarino, 1992).
Hospitals are responding to this initiative by implementing patient-focused work
redesign strategies. These efforts have resulted in downsizing in an attempt to produce
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flatter organizational structures, fewer levels of hierarchy or specialization, and improved
customer service. Rapid development of this trend has focused on three essential criteria
for meeting current demands of the healthcare marketplace. Institutional success will
depend on patient satisfaction, patient outcomes, and cost reduction.
Providers of patient care services must meet and exceed their patient-customers'
expectations as this is rapidly becoming a top agenda for today and the future. The price
health care providers and institutions pay for dissatisfied customers will be high.
Whiteley (1991) reported that almost 80% of the identifiable reasons why customers
switched to competitors' products had nothing to do with the product itself. The
breakdown of customers' reasons for switching is as follows: 45 percent switched
because service was rude and unhelpful, 20% cited a lack of personal attention, and only
15% switched because of lower cost (Whiteley, 1991). The implications of this study
present powerful incentives to health care providers. If product quality is equated with
technical expertise in healthcare then the most technically advanced hospital in the world
would only satisfy 20% of its customers if the evaluation were based on technical
expertise alone. Clearly, technical know-how is not enough.
The new patient-focused model crosses traditional departmental lines. In this
model, the patient is the center of activity. A patient-focused center takes health care
professionals off the assembly line and puts them to work on teams, empowering them to
build a quality product. In a patient focused team, staff people receive sufficient cross
training so they can treat patients with a similar diagnosis from admission to discharge.
The patient-focused unit becomes a mini-hospital designed to bring services closer to the
patient's bedside. This replaces the necessity that the patient struggle with traditional
hospital operations which have become a maze of inefficiency and an endless line of
nameless faces. At one hospital the goal of the first of its focused-care centers is to meet
more than 80% of all patient needs with staff and equipment delivered right to the patient
unit (Troup, 1992).
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Interpersonal Aspects of Treatment
In his classic text, Explorations in Quality Assessment and Monitoring, Avedis
Donabedian, M.D. (1980), has written that there are two primary components to a health
care practitioner's performance: technical quality and management of the interpersonal
relationship. Technical care is measured by comparing it to standards of care and
expected outcomes as established by the scientific literature and supplemented by expert
opinion. Physicians and nurses evaluate the content quality of the technical care.
Interpersonal care is assessed directly, in an analogous fashion, by comparing the way it
is conducted to "standards" which, are primarily evaluated by and based upon the
expectations of patients and their families. The interpersonal process can also be assessed
by its "specific" outcome which, in this case, is patient satisfaction. The delivery quality
is associated with the interpersonal relationships on which the delivery of any service is
based. The interpersonal process is important because patients and practitioners value
certain aspects as desirable. It is also believed that certain management styles are more
conducive to patients' participation in care. The interpersonal aspect of care is often
overlooked, the technical side being viewed as of primary importance. However, the
interpersonal process is the vehicle for technical care in almost all cases.
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According to Donabedian, the practice of medicine is a process that results in an
output. However, it is not the output alone. The quality of an output is arrived at from the
customers point of view, the measure is determined via an evaluation. It is formed from
the individual's perceptions of the output and is rooted within the individual's frame of
reference (Donabedian, 1980).
A recent survey (Ruben, 1993) found that patients placed a high priority on
personal concern, interpersonal communication and relationships. From the patients'
perspectives, the interpersonal treatment they receive forms a more lasting impression of
the healthcare agency than do the clinical and technical aspects of care.
The Measurement of Satisfaction
One patient survey that uses an assessment of needs approach is the
Picker/Commonwealth Patient-Centered Care survey. This survey instrument is designed
to elicit reports from patients about concrete aspects of their experience in lieu of the
ratings of satisfaction generally used on patient surveys. One aspect of the survey that
distinguishes it from other patient satisfaction surveys is that it focuses on eliciting
reports about highly specific, clinically important elements of care. Patient reports about
discrete events provide information very different from general evaluations. Responses to
questions about satisfaction usually depend on both an evaluation and an emotional
reaction. Reports on the other hand, reflect patients perceptions of what actually
occurred. Reports are less likely than
ratings to be influenced by expectations, personal relationships, gratitude, or response
tendencies related to gender, class, or ethnicity (Cleary, Edgman-Levitan, Walker,
Gerteis, & Delbanco, 1993).
The Picker/Commonwealth Survey was administered to 6,455 patients in 62
hospitals. The results from this study have been used to make recommendations
regarding coordination of care at the bedside, coordinating clinical support and ancillary
services (Gerteis, 1994), identifying gaps in service due to age and severity of illness bias
(Cleary, Edgman-Levitan, McMullen, & Delbanco, 1992), and utilization of patient
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generated information in the improvement of quality of care (Cleary, Edgman-Levitan,
Roberts, Moloney, McMullen, Walker, & Delbanco, 1991).
Cleary et al. (1992) explored various factors that were hypothesized to influence
patients' level of satisfaction with their hospital care such as patient demographics (age,
sex, education, income), patient health status, patient preferences for being more or less
informed and involved in their own care, and patient reports on problems that relate to
specific processes of care (e.g., physical care, emotional support, pain management).
Although these factors were significant, they did not account for the total variance in
satisfaction reports. The actual care given still accounted for the largest proportion of the
variance in the satisfaction rating. These authors, utilizing the Picker/Commonwealth
Inpatient Survey, found that there were correlations between patient satisfaction and
health status, age, and sex. The strongest predictor was health status with healthier
patients giving better evaluations of their treatment. Women tended to be more satisfied
with their care than did men, and older patients were more satisfied than younger
patients. Patients who preferred more involvement in their treatment and low income
patients tended to give worse evaluations of their care. The original study used a patient
assessment of health status and the authors recommend that it would be useful to have an
independent assessment of health status in future studies (Cleary et al., 1991).
Breast Cancer Treatment
Cancer is a major health problem in this country. Although mortality rates for
other diseases such as heart disease, stroke, and other conditions have been decreasing,
deaths due to cancer have been on the rise, accounting for 23% of all deaths in the United
States. There have also been increases of indicated cases in the major sites of the disease,
which includes lung, prostate, and breast cancer. For women, breast cancer accounts for
32% of all new cases. During this decade alone, more than 1.5 million women will be
diagnosed and 30% of these women will die from the disease. The incidence of breast
cancer continues to rise despite major clinical studies which include trials of dramatic
treatments such as bone marrow transplantation. Increasing numbers of women undergo
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difficult therapies, and somehow cope with 5-year relative survival rates of 53% for
White Americans and 38% for Black Americans (American Cancer Society, 1993).
Treatment for breast cancer may include surgery, radiation, and chemotherapy or
combinations of these. Surgical mastectomy or lumpectomy require physiologic
recovery, and exercise is needed to restore the range of motion to the affected arm. Side
effects of chemotherapy or radiation may include nausea and vomiting, hair loss, fatigue,
anorexia, skin reactions, and pulmonary effects. Emotional responses to surgery,
radiation, and chemotherapy for breast cancer may include depression, generalized
anxiety, death anxiety, confusion, and a preoccupation with health (Andersen, Anderson,
& DeProsse, 1989).
Much of the psychological research in cancer rehabilitation has been focused on
preventing or reducing psychological and behavioral burdens associated with treatment
and towards improving the quality of life. Several studies have documented that quality
of life benefits, such as reduced emotional distress, enhanced social adjustment, pain
reduction, and so forth, accrue from a psychosocial intervention offered to cancer
patients. These studies clarify the importance of psychological and behavioral factors for
cancer patients and the routes by which such factors may have important health
consequences (Andersen, Kiecolt-Glaser, & Glaser, 1994).
The well publicized study of Spiegel, Bloom, Kraemer, & Gottheil (1989) reports
the positive effects of weekly supportive group therapy on survival time in patients with
metastasized breast cancer. The authors reported that advanced breast cancer patients
who participated in professionally guided support groups lived, on the average, twice as
long as members of a control group who did not attend support groups. The group
therapy seemed to have extended women's lives by an amount that Spiegel et al. (1989)
considered to be both statistically and clinically significant. Further signs of progress in
the area of previously neglected factors of interpersonal and social support emerge
through the work of Blanchard, La Brecque, Ruckdeschel, & Blanchard (1990). These
investigators have developed techniques for studying the doctor-patient relationship
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within the milieu of hospital rounds as well as the effects of medical staff behaviors in
relation to specialty units (Blanchard et al., 1990). It is felt the fears and uncertainty with
treatment outcomes increase the need for interpersonal support and reassurance, and that
from the patients' point of view, the most painful issue of all, is the emotional and social
adjustment to living as a cancer survivor.
Rationale for the Study
It is apparent that treatment for cancer is demanding
and drains a patient's physical and psychological resources.
The interpersonal aspects of care and the support provided
during treatment appear to have significant benefit in
quality of life and emotional adjustment. In light of this
significance, the overall priority of patient satisfaction
in assessing quality of care, and the priority of the MGH
Cancer Center Patient Focus Team, this study attempted to
evaluate the overall satisfaction and the interpersonal
satisfaction with care delivered by the MGH Comprehensive
Breast Health Center. Demographics, particularly type of
treatment, were examined to determine if they influenced the
satisfaction ratings.
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METHOD
Subjects
The subjects were a convenience sample of 100 women who were randomly
selected from the Comprehensive Breast Health Center (CBHC) of the MGH. This clinic
provides routine screening, new problem evaluation, multidisciplinary sessions for newly
diagnosed breast cancers,as well as patient teaching and support services. To participate
in the study, patients must have been diagnosed with biopsy-proven breast cancer and
have received treatment; surgery and radiation and/or chemotherapy. All patients
interviewed have had multiple visits to the CBHC, due to having experienced surgery
and some type of adjuvant treatment. It was expected that subjects would have had
sufficient exposure to the CBHC so that their judgments could be validated. Patients
were excluded from the study if they were found to be in a nursing home or rehabilitative
facility. The following additional exclusionary criteria limited the scope of this study due
to lack of funding. Subjects unable to speak and comprehend English were excluded.
Subjects from countries other than the United States were also excluded.
Dependent Measures
Patient satisfaction was measured via a structured interview. The format for the
interview was a modification of the ambulatory care and inpatient versions of the
Medical/Surgical Patient Interview developed by the Picker/Commonwealth Program for
Patient-Centered Care. The mission of the Harvey and Jean Picker Institute is to promote
approaches to health care quality assessment and improvement. The Picker Institute is a
non-profit subsidiary of the Beth Israel Corporation. The focus of their work is to address
patients' needs and concerns and to foster the improvement of health care so that patients'
experiences of illness and the health care system are more humane. Much of the work of
the Institute centers around identifying factors that influence patients' experience of the
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health care system. A family of surveys has been developed by Picker Institute staff
which is research-based, field-tested, and validated. These instruments are designed to
generate reports from patients about concrete aspects of their experience, as opposed to
general ratings of satisfaction so often used in patient surveys. Based on previous studies
and a literature review, Cleary et al. (1991) developed the survey questions following a
multi-step process that involved patients, family members, friends, and health care
providers. The questions were designed to concentrate on specific actions taken by
hospital staff rather than on general aspects of care. Seven dimensions of patient-centered
care were identified. Most response options were dichotomous (yes/no), with some
Likert-type ratings, and some follow-up questions to allow for elaboration of
information. The authors calculated an index of quality of care by calculating the
percentage of all questions in that area that had responses indicating a problem. Scores
ranged from 0 percent (no problems in an area) to 100 percent (all responses in that area
were indicated to be problems). Scores for each area were averaged to compensate for
the different number of questions in each area. The Picker/Commonwealth inpatient
survey was used in two randomized national surveys of recently-discharged hospital
patients in 1989 and 1993 to provide normative data on the quality of care in U.S.
hospitals (Cleary et al., 1991; Cleary et al., 1992; Cleary, 1993). The first study had a
sample size of N = 6,455 (Cleary et al., 1991). The measure was revised in January of
1992 based on the data obtained and on feedback from the investigators. The
Picker/Commonwealth survey is able to discriminate clearly among hospitals due to a
sufficiently wide range of responses to problem areas. Additionally, problem scores have
correlated well with other objective assessments of technical quality of care. The measure
has been found to have adequate face and construct validity (J. Walker, personal
communication, September 1, 1994).
The Picker/Commonwealth Ambulatory Care Patient Interview was designed to
provide a patient evaluation of a recent visit to one's health care provider. It consists of
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74 items, including the demographic questions. It was based upon the earlier work with
the inpatient survey and is still being refined.
The Ambulatory Care Patient Interview served as the foundation for the study
survey. However, it did not cover all the areas to be examined. Therefore, questions from
the inpatient survey that related specifically to type of care given at the CBHC were used
as well. Additionally, the ambulatory care questionnaire focuses on the most recent visit.
This aspect was changed to address the entire course of treatment that was recently
completed or still continuing at the time of the survey. Also, changes included the
elimination of items relating to medical visits to facilities other than the clinic in question
(e.g., emergency room, urgent care center).
As the survey was modified, it was presented to numerous clinical and
administrative personnel from MGH to obtain feedback and input for improved relevance
to the CBHC and the Cox Cancer Center Patient Focus Team Report.
There resulted two distinct content areas, one being the interpersonal aspects of the
treatment and the other being the Focus Team outcomes. The survey yields an Overall
Satisfaction score, and scores for the subsections of Environmental Comfort and
Emotional Support. There is also a score reflecting satisfaction with the interpersonal
aspects of care. Additionally, all items were evaluated on an individual basis in order to
provide feedback to MGH on the quality of their Focus Team outcomes.
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Independent Measures
Demographic Variables. Analyses were run to determine if there were any
differences in responses correlated with demographic variables such as age, HMO
enrollment, choice of provider or type of adjuvant treatment. This information was
gathered as part of the modified Picker/Commonwealth survey.
Data Collection
The random selection was accomplished by choosing every 3rd patient on a
surgeries list generated by the CBHC. The subjects were drawn from the surgeries list
beginning with patients who began treatment in February 1994, up to November 1994.
Patients were sent a letter from the CBHC explaining
that they may be contacted to participate in a patient
satisfaction study (see Appendix). This letter explained the
purpose of the study, the fact that responding was strictly
voluntary and also provided the name and phone number of a
contact person at MGH if there were any questions. The
letter was mailed one week prior to telephone contact. When
the patient was reached by phone they were asked to
participate, and if they gave consent, the interview
occurred. If the time was not convenient, an appointment was
made to interview the patient at a later date. Responses
were recorded on the survey form which was identified by
subject identification number only to ensure patient
confidentiality. The master list with patient information
was held at the MGH Cancer Center by the Project Manager,
Jonathan Mello.
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