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

2

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).

3

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).

6

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.

9

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

14

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

15

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.

16

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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