AIDS Patient Satisfaction With Hospitalization in the Era of Highly Active Antiretroviral Therapy

HIV/AIDS Patient Satisfaction With Hospitalization in the Era of Highly Active Antiretroviral Therapy Robert J. Wolosin, PhD

The purpose of this study was to investigate how HIV/AIDS patients evaluate hospitalizations and to contrast such evaluations with those of inpatients who were diagnosed with pneumonia or pleurisy. In all, 302 satisfaction survey records collected in 2002 from patients of U.S. hospitals were analyzed. Potential confounding variables were kept constant or statistically controlled. Patients with HIV/AIDS rated their care lower than patients with pneumonia or pleurisy. The survey section, Tests and Treatments, yielded a significant effect of diagnosis. In addition, there was a significant effect of diagnosis for two survey items: skill of the person who took your blood, and skill of the person who started the intravenous line. Results were discussed in terms of caregiver attitudes toward HIV/AIDS patients, and implications for nursing care were drawn. Key words: acquired immunodeficiency syndrome, HIV, patient satisfaction, quality of care

Crossing the Quality Chasm (Institute of Medicine, 2001), the Institute of Medicine’s strategic design for improving the quality of health care in America, identified HIV/AIDS as a potential priority condition around which to organize immediate quality improvement efforts. HIV/AIDS was included on the basis of its prevalence, expense, and chronicity; it had been identified earlier by the Veterans Health Administration and by the Medical Expenditure Panel Survey as an important quality improvement focus. Satisfaction with care is well recognized as a measure of medical quality (Press, 2002). It is related

to patient adherence to medical regimens (Ware & Hays, 1988), medical and surgical outcomes (Kenagy, Berwick, & Shore, 1999), and malpractice suits (Hickson et al., 2002), among other things. The quality of care delivered during the inpatient stays of patients with HIV/AIDS, as indexed by patient satisfaction, may be problematic. First, such stays often occur in response to serious acute illness, and much diagnostic and therapeutic activity must take place in a relatively short time. These circumstances create numerous challenges (Wilson et al., 2002). Moreover, HIV/AIDS has been culturally constructed as a stigmatized condition, and the persons who suffer from it may feel ostracized and isolated, especially in the unfamiliar surroundings of the hospital (Lentine et al., 2000; O’Rourke, 2001; Poindexter & Linsk, 1999). As recently as 2000, more than one in six adults polled in a national telephone survey responded that persons who acquired AIDS through sex or drug use have gotten what they deserve (Lentine et al., 2000). Furthermore, caregivers may have personal difficulty providing the best care to patients with HIV/ AIDS. As representatives of the larger culture from which they are drawn, doctors and nurses are not immune to widely held images and stereotypes. Two studies are representative of the literature on caregiver attitudes. In the first, Webb, Bower, and Gill (1997) conducted a survey in a large, tertiary care Robert J. Wolosin, PhD, is Research Product Manager at Press Ganey Associates, Inc., South Bend, IN.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 16, No. 5, September/October 2005, 16-25 doi:10.1016/j.jana.2005.07.002 Copyright © 2005 Association of Nurses in AIDS Care

Wolosin / HIV/AIDS and Patient Satisfaction

teaching hospital and found that, despite their knowledge of HIV/AIDS, nurses felt fearful and vulnerable when providing care to patients with HIV/AIDS. Moreover, some nurses reported a preference for avoiding assignments with HIV/AIDS patients. A second study (O’Sullivan, Preston, & Forti, 2000) examined the attitudes of critical care nurses in rural counties across the northeastern United States and found that nurses differed in their willingness to care for patients with HIV/AIDS. Feelings of being prepared to care for patients with AIDS promoted such willingness, but fear of contracting HIV/AIDS and concerns about not knowing how to protect themselves from the disease decreased it. Undoubtedly, the vast majority of healthcare workers are able to overcome any pre-existing negativity toward patients with HIV/AIDS and deliver high-quality care, but these studies indicate a potential source of difficulty in achieving that end. Furthermore, consider the behavior of HIV/AIDS patients themselves. A recent qualitative study noted that violent and angry behaviors are “frequently reported by health care workers in HIV/AIDS treatment settings” (Kemppainen, O’Brien, & Corpuz, 1998). This study of hospitalized male and female patients with AIDS found that one third of the patients described critical incidents involving angry behaviors directed toward nurses. The behaviors included yelling, slamming objects, and even throwing things at the nurses. More female patients reported angry behaviors than male patients. Although only a minority of AIDS patients reported such incidents, it is easy to imagine that the potential for angry or violent behavior on the part of any patient might make for caregiver caution or wariness when approaching such a patient. Given the difficulties regarding treatment, attitudes, and behaviors summarized above, the achievement of high-quality care of patients with HIV/AIDS requires considerable effort on the part of hospital personnel. To what degree does such care occur in the hospital setting? The existing literature is sparse. For example, in an early pilot study, Cleary et al. interviewed 50 AIDS patients hospitalized in a large, metropolitan tertiary care center about various aspects of their care such as communication and emotional support from providers (Cleary et al., 1992). Average satisfaction was 2.3 on a scale of 1 (excel-

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lent) to 5 (poor). Responses to open-ended follow-up questions from those interviews were subsequently reported (Foley & Fahs, 1994). Although patients were generally satisfied with their care, most reported at least one troublesome issue such as depersonalizing behaviors on the part of staff (e.g., using two gloves and two masks, being afraid to touch the patient, or ignoring the patient entirely). More recently, Jones, Messmer, Charron, & Parns (2002) surveyed 50 HIV-positive persons from four centers/hospitals in South Florida and found them to be generally satisfied with their care. However, patients reported problems with pain management and education on drug side effects. Wilson et al. (2002) reported the results of a national probability sample survey of persons in care for HIV in 1996, shortly after the introduction of highly active antiretroviral therapy (HAART). Personal interviews were conducted with HIV/AIDS patients regarding a recent hospitalization or outpatient experience; patients who reported a recent hospitalization were asked 10 questions regarding the quality of hospital care during “your hospital stay(s) in the last 6 months.” Wilson et al. found that problems with coordination and integration of care and issues of pain control were cited most often. Relatively few patients reported problems with respectful treatment or help with physical functioning. HIV/ AIDS patients’ global ratings of care were significantly lower than those of a national sample of hospitalized patients matched for age, gender, and health status. Nonetheless, they noted that providers “have much room for improvement” and called for better provider-patient communication. The studies reviewed above, with the exception of the last, do not compare the responses of HIV/AIDS patients with those of other patients, making it impossible to conclude whether their responses are in any sense distinctive or unique. It could be that patients with other infectious illnesses report similar levels of satisfaction with hospital care, so that singling out patients with HIV/AIDS is misleading. A study that did use comparative data was conducted by Webb et al. (1997). These investigators compared satisfaction with aspects of nursing care among 42 hospitalized HIV/AIDS patients with that of 50 patients diagnosed with non-HIV/AIDS infectious diseases and 50 patients with a medical diagnosis other

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than infectious disease. Aspects of nursing care that were assessed included technical nursing activities, characteristics necessary for a trusting relationship between patient and nurse, and communication of information. They found that non-HIV/AIDS medical patients were more satisfied with their nursing care than HIV/AIDS patients; patients with diagnosed infectious diseases other than HIV/AIDS gave ratings that were between those of the other groups. There was a trend in the data toward patients with HIV/AIDS having less trust in their caregivers than patients with other medical diagnoses. The utility of the most representative study that directly addresses satisfaction with HIV/AIDS inpatient care (Wilson et al., 2002) is limited by the fact that it was conducted shortly after the introduction of HAART, before it came into widespread use. Since the introduction of HAART, HIV/AIDS patients’ hospitalizations have decreased in absolute number (Gebo, Diener-West, & Moore, 2001; Paul et al., 2002). The nature of the diseases for which patients with HIV/AIDS are hospitalized has changed as well (Jones, Hanson, Dworkin, De Cock, & Adult/Adolescent Spectrum of HIV Disease Group, 2000; Paul; Wolff & O’Donnell, 2001) Moreover, research and testing regarding the complex HIV medication regimens involved in HAART has revealed a number of problematic issues that are relevant to patient satisfaction. First, it has become apparent that HAART use may have its own complications over and above those associated with HIV/AIDS (Barbaro & Klatt, 2003; Kuritzkes & Currier, 2003). A recent review noted the association of HAART use with coronary heart disease, cerebrovascular events, and systolic hypertension (Havlir & Currier, 2003). (Some of these associations remain controversial at this time, because other investigators report no relation between the use of particular HAART medications and cardiovascular or cerebrovascular events [Bozzette, Ake, Tam, Chang, & Louis, 2003].) Secondly, much evidence has accrued regarding the centrality of adherence issues in complex HIV medication regimens (Abel & Painter, 2003; Adam, Maticka-Tyndale, & Cohen, 2003; Brackis-Cott, Mellins, Abrams, Reval, & Dolezal, 2003; Marelich, Johnston-Roberts, Murphy, & Callari, 2002; Reynolds, 2003; Russell et al., 2003). For example, it was found that patient-provider relationships and weight gain were important

determinants of adherence among a group of female patients with AIDS (Abel & Painter). The implication from the latter studies is that the population of hospitalized patients with HIV/AIDS may be composed of more nonadherent patients than was previously the case. Considered as a whole, the evidence suggests that hospitalized patients with HIV/AIDS may have different reactions to hospitalization than at the time of the Wilson et al. study. The aim of the current study was to investigate the state of patient satisfaction with HIV/AIDS inpatient care in the HAART era. It did so by comparing ratings of care from HIV/AIDS patients with those of medical patients hospitalized at the same time, in the same set of facilities, with comparable although nonstigmatizing diagnoses to determine the degree to which HIV/AIDS patients’ scores are distinctive. The study used data from a national database of patient surveys.

Methods This study was a retrospective database study, drawing on hospitalized patients’ survey responses maintained in the Press Ganey national database. Press Ganey is a firm that specializes in satisfaction measurement within the healthcare industry; it collects and houses data for hospitals across the United States for the purposes of quality improvement and benchmarking. Instrument All data and measures come from the Press Ganey Inpatient Survey. The conceptual model that forms its basis is the set of major components of an inpatient visit. The instrument consists of several demographic items (e.g., age and gender of patient) and 49 items that ask the responding patient to rate specific aspects of inpatient care. For each item, the patient is asked to provide a numeric evaluative rating of an aspect of care, such as speed of the admission process, rather than to express agreement or disagreement with a statement. The items are arranged into sections that correspond to the salient parts of an inpatient stay: admission, room, nurses, physicians, discharge, and so on. Items are rated on a balanced

Wolosin / HIV/AIDS and Patient Satisfaction Table 1.

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Frequency of Diagnosis-Related Groups (DRGs) in Sample

DRG

Explanation of DRG

Frequency

Percentage

89 90

Simple pneumonia & pleurisy, age ⬎ 17, with complications Simple pneumonia & pleurisy, age ⬎ 17, without complications Subtotal HIV with major related condition HIV with or without other related condition Subtotal Total

109 42 151 115 36 151 302

36.1 13.9 50.0 38.1 11.9 50.0 100.0

489 490

5-point, Likert-type scale ranging from 1 (very poor) to 5 (very good). Responses are converted to a 100point scale by a linear transformation for analysis and reporting purposes. This instrument is described in Appendix 1 and elsewhere (Kaldenberg, Mylod, & Drain, 2002). The Inpatient Survey is used by acute care hospitals that employ Press Ganey to provide patient satisfaction measurement services. These include 40% of all acute-care hospitals having more than 100 beds in the United States. A single-wave mail-out, mail-in method is used to reduce the tendency to acquiesce to an interviewer’s presumed preferences or to present oneself in a positive light. Such tendencies can bias the results of face-to-face or telephone surveys (Hall, 1995; Press, 2002; Ware, 1995). Surveys are mailed to patients within 1 week of their hospital discharge. The average return rate is 25% to 30%. Sample Selection To be in the sample, a patient’s survey had to be (a) received for processing in 2002, (b) from a hospital that treated at least one patient with HIV/AIDS, and (c) coded as a diagnosis-related group (DRG) by the treating hospital that indicated medically treated HIV/AIDS or pneumonia/pleurisy. (Surveys that contained HIV/AIDS DRGs indicating surgical treatment were excluded from this analysis. The course of hospital treatment of surgical patients is sufficiently different from that of medical patients to cause them to have a different profile of satisfaction ratings; including their records would have diminished the internal validity of the study.) Pneumonia and pleurisy were chosen as comparison diagnoses because they are infectious diseases and affect lung function

as do tuberculosis and Pneumocystis carinii pneumonia, which are among the causes of hospitalization of patients with HIV/AIDS. However, pneumonia and pleurisy do not carry the stigma of HIV or AIDS. These criteria yielded a set of 2,518 survey records, 2,334 representing patients with pneumonia/ pleurisy and 184 representing patients with HIV/ AIDS. The age-sex distribution of patient records within diagnosis indicated that patients with HIV/ AIDS were younger and more often male than patients with pneumonia/pleurisy. To control for the potentially confounding effects of age and sex, equal-sized random samples of patient records within diagnosis-age-sex categories were drawn. In addition, records from patients who were under the age of 17 or whose age or sex could not be determined were eliminated from the analysis. This procedure resulted in a sample, shown in Table 1, of 151 patients representing each diagnostic category (HIV/AIDS or pneumonia/pleurisy). Facility Characteristics Patients from 66 hospitals provided data for this study. The hospitals ranged in number of beds from 48 to 1,025, with a median number of beds of 408. The hospitals were located in 25 states, representing all nine American Hospital Association regions. Patient Characteristics Table 2 shows the demographic and hospitalization characteristics of the sample and shows that the two types of patients differed in some respects. Despite the matching procedure, patients with HIV/ AIDS were slightly younger than pneumonia/pleu-

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Table 2.

Demographic and Hospitalization Characteristics of Sample, by Diagnosis

Characteristic

Sex (% male) Age (median) Age category (%) 18-34 years 35-49 years 50-64 years 65-79 years First stay (%) ER admit (%) Length of stay (days) Special diet (%)

Diagnosis Pneumonia/ Pleurisy

HIV/AIDS

81.5 45.5

81.5 43.0

— .075

12.6 61.6 23.2 2.6 52.9 79.2

12.6 61.6 23.2 2.6 50.0 70.9

— — — — .742 .175

4.81 33.8

6.94 29.1

p

⬍.001 .258

NOTE: ER ⫽ emergency room.

risy patients. In addition, HIV/AIDS patients’ hospitalizations were (a) less likely to be their first stay in the particular hospital, (b) less likely to have been initiated through the emergency room or to have been unexpected, (c) longer, and (d) less likely to have included a special diet. In addition, the age distribution of this sample of patients with HIV/ AIDS was compared with national statistics from 2001 and showed that the sample had proportionally fewer patients in the 18- to 34-year-old range and proportionally more in the older age ranges (National Center for HIV STD and TB Prevention Divisions of HIV/AIDS Prevention, 2001). Data Analysis Survey records were analyzed using Statistical Package for the Social Sciences, Version 11.0 for Windows (SPSS, Inc., Chicago, IL). Before analysis, records were deidentified in accordance with American Health Insurance Portability and Accountability Act of 1996 regulations. Differences in distribution across demographic variables as well as hospitalization characteristics were tested by t test (for continuous variables) or chi-square (for dichotomous variables; Table 2.) Length of stay differed significantly (p ⬍ .001) between the two groups; the other variables did not.

Therefore, survey section scores were analyzed using analyses of covariance with diagnosis (HIV/ AIDS vs. pneumonia/pleurisy) as the fixed factor and length of stay as the covariate. When the section score analysis of covariance showed a significant effect of diagnosis, it was followed by analyses of covariance of the items of which the section was composed. Because of significant heterogeneity of variance in the dependent variables, the probability of a Type I error was set to a relatively stringent value of ␣ ⫽ p ⬍ .001 (Tabachnick & Fidell, 2001).

Results Table 3 shows means, standard deviations, and the results of analyses of covariance for survey section scores. For each survey section, the mean rating of HIV/AIDS patients was lower than for the corresponding rating of pneumonia/pleurisy patients. Ratings for the Tests and Treatments section were significantly (p ⬍ .001) lower for patients with HIV/ AIDS than for patients with pneumonia/pleurisy. Follow-up analyses of covariance on the items of which that section was composed indicated significantly (p ⬍ .001) lower ratings of two items: skill of the person who took your blood and skill of the person who started the intravenous (IV [line]). Means of all Tests and Treatments items are shown in Figure 1; they indicate that for every item, the mean rating of patients with HIV/AIDS was lower than that of patients with pneumonia/pleurisy. Examining the two items that showed a significant difference in ratings, the first was skill of the person who took your blood. This item measures the extent to which the actions of the phlebotomist met the patient’s expectations. Patients judge a phlebotomist’s interpersonal as well as technical skill. Because phlebotomists typically have very brief, technically focused interactions with patients, the major source of data for this judgment is the proficiency with which the patient’s blood is drawn. If the phlebotomist applies the tourniquet to the patient’s arm quickly, locates an accessible vein on the first try, inserts the needle into the patient’s vein smoothly and quickly, and withdraws the needle without discomfort to the patient, his or her skill is likely to be judged high. The degree to which these tasks are not

Wolosin / HIV/AIDS and Patient Satisfaction Table 3.

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Means, Standard Deviations, and Summary of Analyses of Covariance of Survey Sections

Survey Section

Pneumonia/Pleurisy Admission Room Meals Nurses Tests and treatments Visitors and family Physician Discharge Personal issues Overall assessment

Summary of Analyses of Covariancea

Diagnosis HIV/AIDS

Mean

SD

Mean

SD

df

F

p

76.52 75.89 73.92 84.03 82.72 81.92 82.82 80.06 79.70 84.81

22.50 18.56 20.28 19.92 18.01 19.02 21.80 22.25 20.31 20.22

75.64 75.82 70.23 79.46 77.20 80.46 79.46 77.59 76.50 80.75

21.37 18.95 23.82 23.85 19.90 20.38 23.55 21.96 22.54 24.87

1,239 1,252 1,249 1,251 1,247 1,235 1,247 1,247 1,244 1,245

0.600 2.360 7.370 5.540 12.730 6.510 6.450 3.510 7.960 5.940

.440 .125 .007 .019 .000 .011 .012 .062 .005 .016

a. In each analysis of covariance, diagnosis (HIV/AIDS vs. pneumonia/pleurisy) was the fixed factor tested by the F-statistic, and length of stay was the covariate.

Figure 1. Mean Ratings of Items From Tests and Treatments Survey Section. Shaded Bars Indicate That the Ratings Differed, p < .001. NOTE: IV ⴝ Intravenous. Scale Is a 100-Point Scale.

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done in such a way is likely to downgrade the patient’s judgment of the phlebotomist’s skill. For example, multiple attempts at needle insertion or lengthy procedures will be viewed by the patient as signs of inexperience or incompetence. Related behaviors such as visible anxiety, forgetting equipment, clumsiness, or dropping things will also decrease the patient’s perception of the employee’s skill. Skill of the person who started the IV was the other item that differed between the two groups of patients. Analytically, it is quite similar to the previous question. Patients judge the IV starter’s interpersonal as well as technical skill. Like phlebotomists, IV starters typically have very brief, technical interactions with patients. The proficiency with which the patient’s vein is punctured and the IV inserted, the bag hung, and the infusion started contribute to the patient’s judgment of IV-starter skill. Because patients prefer that unpleasant experiences be as short as possible, a skillful employee will find an appropriate insertion site quickly and insert the IV needle smoothly and quickly. Multiple attempts at needle insertion or lengthy procedures will be viewed by the patient as signs of inexperience or incompetence. Just as for phlebotomists, visible anxiety, forgetting equipment, clumsiness, or dropping things on the part of the IV starter will decrease the patient’s perception of that employee’s skill. These findings were obtained in such as way as to reduce potential threats to internal validity. HIV/ AIDS patients’ scores were contrasted with those of pneumonia or pleurisy patients treated in the same set of treatment facilities, at the same time, and surveyed in a manner that reduces response bias. Two potentially confounding demographic variables, namely patient sex and age, were eliminated by matching the samples on those characteristics. Length of stay, which was significantly longer for HIV/AIDS patients, was controlled for via analysis of covariance. While analysis of covariance cannot eliminate the possibility that differences in rated satisfaction are because of differences in the two groups of patients’ length of stay, it is the most appropriate technique for dealing with nonexperimental data in which groups differ in some unwanted fashion (Tabachnick & Fidell, 2001).

Discussion The most striking results to emerge from this study of quality of inpatient care for patients with HIV/AIDS were the differences in the two items from the Tests and Treatments survey section. Both of these items pertain to skills related to contact or potential contact with bodily fluids. The author can only speculate as to why ratings of these two items in particular were affected by patient diagnosis. However, it is at least plausible that any fears of contamination or infection with HIV are most salient in this context, in which the skin of the patient must be penetrated, and care must be taken to prevent the patient’s blood from spilling or dripping on an exposed surface of the caregiver’s body. In this highly charged context, caregivers might overtly or covertly betray their fears. Writing a few years ago, Webb et al. (1997) declared, “Nurses continue to have low knowledge and high fear about caring for HIV/AIDS patients” (p. 45) More recently, a British physician quoted one of his house officer’s reactions to an HIV-infected patient thus: “I’m not going in there: I’m not taking blood from him, and I’m not resetting his drip. . . I am not risking getting some horrible disease from a needlestick. It’s not that I’m a gay-basher; I’ve got some really good friends who are gay . . . but this guy is probably a junkie, and that’s plain stupid” (p. 123; O’Rourke, 2001). Implications for Nursing Care The implications for nursing care from this study are straightforward. First, it would be important for personnel to discuss with HIV/AIDS patients the latter’s expectations regarding blood draws and IV needle insertions. It is possible that some patients recognize the meaning of the situation for their caregivers and may have worked out ways that minimize their own discomfort as well as the likelihood of caregiver infection. It would be well to discover such ways if they existed, or, by soliciting the patient’s opinions, invent ways if they did not. Such a discussion at the very least improves the caregiving situation by making public what may be present but covert in everybody’s mind. It also has the potential to increase the patient’s sense of ownership of treat-

Wolosin / HIV/AIDS and Patient Satisfaction

ment and increase cooperation with other aspects of care, because the underlying message is that the patient’s ideas are worthy of consideration. Second, enhanced practice opportunities with HIV/AIDS patients might be provided to staff to increase their technical proficiency with phlebotomy and IV needlesticks. Depending on circumstances, a hospital might develop a specialized team that handles most or all blood-related tasks with HIV/AIDS patients. Finally, values clarification for nursing personnel can be instituted or increased. The goal of such training would be recognition of and ways of handling untherapeutic attitudes toward patients with HIV/AIDS. The involvement of actual patients with HIV/AIDS as part of the educational team (compare Reiser, 1993) would allow caregivers to hear patients’ perspectives and may work to diminish stereotypes on the part of both caregivers and patients.

Limitations The study is limited by the selection of participating facilities. Although participating facilities represent a broad array of hospitals from all regions of the United States and because of their participation in patient satisfaction measurement efforts are more likely to value quality improvement as an organizational goal, the fact remains that the hospitals in the Press Ganey national inpatient database are not a random selection of all American hospitals. In particular, hospitals with fewer than 100 beds are underrepresented. On the other hand, with 32% of all U.S. hospitals included, the Press Ganey inpatient database is the largest and most comprehensive and representative repository of patient satisfaction from inpatient settings available. The evidence from the current study can be summarized: HIV/AIDS patients’ satisfaction with their care is consistently lower than that of comparable patients with pneumonia or pleurisy. Further research will be needed to determine the exact parameters of such differentials (e.g., variation by hospital characteristics such as size, locale, and whether patients with HIV/AIDS are treated in a specialized unit) as well as the mechanisms through which differentials occur. In that way, we might learn how to increase the quality of HIV/AIDS care, not only for the cur-

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rent cohort of inpatients but also for the next—the women, minorities, and poor who are increasingly represented in the HIV/AIDS epidemic (Karon, Fleming, Steketee, & De Cock, 2001).

Appendix The Press Ganey Inpatient Survey was first developed in 1987. The conceptual model behind the ratings is real-world based in that it derives from typical experiences a patient may actually encounter during a hospital stay. Events that occur (admission, meals, tests or treatments, discharge), personnel encountered (nurses, physicians, and technical staff), the physical surroundings (room and hospital), and the interpersonal aspects of the stay are seen as important contributors to the patient’s total experience. These factors are also believed to be reflections of the quality of the medical care delivered and received. The Inpatient Survey was revised in 1997 and revalidated in 2002 to reflect changes in health care. During the revalidation, surveys from patients from 721 hospitals in 48 states were analyzed to determine the survey’s psychometric properties. Preliminary review of response frequencies and patient comments found no problems with question ambiguity. Reliability The internal consistency/reliability of the survey was determined by calculating Cronbach’s alpha statistic for each scale and for the entire instrument. Alphas for the scales range from .84 to .95, and Cronbach’s alpha for the entire instrument was .98, confirming its high internal consistency/reliability. Validity Construct validity assesses whether the conceptual model that forms the basis of the survey reflects distinctions made by patients as they fill out the scale. Do patients rate items within a subscale in a coherent way? Construct validity was determined by factor analysis, which yielded nine factors mirroring the subsections of the questionnaire. An item should be correlated with its own scale (convergent validity) as well as correlated more with its own scale than

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with other scales (discriminant validity). Convergent validity is demonstrated by the average correlations between each item and its parent scale, corrected for the contribution made by the particular item in question. Average corrected item-scale correlations for the subsections of the inpatient survey range from .62 to .86. Discriminant validity is shown by the fact that, on average, items from each scale are correlated with items from other scales from .40 to .59. Predictive validity, the ability of an instrument to predict outcomes that theoretically should be tied to the construct measured by the instrument, is measured by the relationship of individual items (and the entire scale) to the patient’s reported likelihood of recommending the facility to others, a measure of positive word-of-mouth. Multiple regression analysis revealed that, collectively, all items are significant predictors of patients’ reported likelihood to recommend the hospital, explaining approximately 77% of the variance in that measure. Readability According to the Flesch-Kincaid Index, the inpatient questionnaire has a reading level between the fifth and sixth grades. More information about the psychometric properties of the Press Ganey Inpatient Survey can be obtained from the author or found in Kaldenberg, Mylod, & Drain (2002).

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