Although hospitals across the country routinely measure and report patient experience and satisfaction survey data internally, until recently few comparative public reports of hospital patient satisfaction have been available. A recent review identified nine states, cities, or regions that publicly reported comparative data on hospital patient experience and satisfaction (Barr et al. 2004). Similar public reports have been found on other websites; however, only five continue to report regularly (Shearer, Cronin, and Feeney 2004). Voluntary national efforts to publicly report on hospital quality include pilot projects that have tested the use of a standardized instrument (the Hospital CAHPS Survey) to measure patient perspectives on hospital care (Centers for Medicare & Medicaid Services 2005). The intent of public reporting is, not only to provide information for consumers, but also to stimulate quality improvement (QI) efforts in hospitals. Yet, there have been few formal studies about the impact of public reports on hospital QI.
Several evaluations of public reports on hospital clinical measures suggest that facilities do make changes in response to these reports. In Wisconsin, a recent evaluation found that, among low scoring hospitals, those involved in public reporting were significantly more likely to report improvement activities in areas included in the public report than were comparison hospitals not involved in public reporting (Hibbard, Stockard, and Tusler 2003). Hospitals in Pennsylvania and New Jersey (Bentley and Nash 1998), Missouri (Longo et al. 1997), and Cleveland (Rosenthal et al. 1998) used public reports of performance to develop new approaches to improve clinical indicators.
What remains unclear is whether public reports of patient experience will similarly result in efforts that can lead to improvement. Only one report in the literature discusses the impact of a hospital patient satisfaction public report on hospitals (Draper, Cohen, and Buchan 2001). Moreover, it is unknown how individual hospitals use these public reports to make changes that would improve their ratings. In order to listen to QI messages and adopt practices for QI, hospitals must be able to identify areas where they need improvement (Halm and Siu 2005) and have a way to track changes. Factors both internal and external to the hospital may affect their adoption of QI (Scanlon et al. 2001), and an organizational structure and culture that supports QI is critical to its adoption (Shortell et al. 1995; Berwick 2003; Bradley et al. 2003). Understanding the process through which hospitals respond to the public release of comparative data based on patient experience can help answer questions about the impact of public reporting on hospitals.
OBJECTIVES
This study explored the impact of mandatory statewide public reporting of hospital patient satisfaction on hospital QI, using Rhode Island (RI) as a case example. In 1998, the state of RI enacted legislation requiring public reporting of clinical performance and patient satisfaction measures by all licensed health care facilities in the state, with two major goals: public accountability and QI. Supported by area hospitals, the law gave responsibility for implementation to the State Department of Health with the advice of a Steering Committee that included both state legislators and virtually all major stakeholders (General Laws of Rhode Island 1998). This mandate set the stage for widespread collaboration on implementing a standardized public reporting program (Barr et al. 2002). The overall objective of the current study was to understand how comparative public reporting on standardized measures of hospital patient satisfaction in RI was used by hospitals for QI. Two research questions were addressed:
1. What QI activities were implemented in response to the public report of patient satisfaction, including collection and use of data to identify and track QI initiatives?
2. What existing structures and processes were in place (both initially and in response to public reporting) in the hospitals to accomplish QI related to patient satisfaction reports, and what were the barriers to and facilitators of QI efforts?
METHODS
Public Report Process
The public report process involved a pilot survey in 2000 with results reported to individual hospitals only, and the first public survey in 2001 with comparative results released to the public (Rhode Island Department of Health 2001 a; Barr et al. 2002). All 11 general, acute-care hospitals in the state and two specialty hospitals, for inpatient rehabilitation and psychiatric treatment, were included in the public report process. Because the surveys were limited to adult patients, the pediatric psychiatric hospital in the state was excluded; also excluded were the Veterans Administration hospital, the state-run long-term care hospital, and rehabilitation or psychiatric units located within general hospitals. Three acute care hospitals in RI are classified as tertiary by state licensing regulations; one is a Level I trauma center. One of the hospitals is an academic medical center, and four are community teaching hospitals (Hospital Association of Rhode Island 2005).
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