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Obstetric patient satisfaction: Asking patients what they like
American Journal of Obstetrics and Gynecology (2004) 190, 175e82
www.elsevier.com/locate/ajog
Obstetric patient satisfaction: Asking patients what they like Elizabeth A. Howell, MD, MPP,* John Concato, MD, MPH Departments of Obstetrics and Gynecology and Health Policy, Mount Sinai Medical Center, the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New York, NY, and the Clinical Epidemiology Research Center, West Haven Veterans Affairs Medical Center, New Haven and West Haven, Conn Received for publication March 17, 2003; revised June 2, 2003; accepted June 10, 2003
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Obstetrics Patient satisfaction
Objective: This study was undertaken to determine pertinent attributes of women’s hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics. Study design: By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction. Results: The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction. Conclusion: A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services. Ó 2004 Elsevier Inc. All rights reserved.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Patient satisfaction has received a great deal of attention in the medical literature and is an important indicator of quality of care.1 In addition, as various health
Supported by a fellowship in the Robert Wood Johnson Clinical Scholars Program at Yale University (E. H.). The opinions, view, and conclusions expressed in this article are those of the authors and not necessarily those of the Robert Wood Johnson Foundation. * Reprint requests: Elizabeth Howell, MD, MPP, Department of Health Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1077, New York, NY 10029-6574. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2003.06.006
plans compete to provide care for groups of patients, much attention has been focused on patient satisfaction as a way to attract and retain patients. Studies have shown that satisfied patients tend to be more adherent to medical recommendations2 and less likely to ‘‘physician shop’’ or disenroll from health plans.1,3,4 Studies on patient satisfaction vary widely, ranging from evaluation of health-related programs, performance of health care providers, to factors that may influence patient satisfaction such as physician gender and patient preferences.5-8 Researchers have investigated the topic of patient satisfaction in the field of obstetrics since the 1970s.9,10
176 Much of the early work examined factors associated with satisfaction rather than clearly defining the underlying construct of patient satisfaction in obstetrics.11 In addition, many of the instruments used were simple measures of satisfaction, with women often asked to rate their experience on a single-item scale (eg, women’s willingness to return to the same hospital for subsequent births was considered an assessment of satisfaction).12,13 Later work shifted to developing tools to measure patient satisfaction. For example, investigators in the late 1980s developed scales to measure important ‘‘soft outcomes’’ of childbirth, with instruments such as the Labor and Delivery Satisfaction Index.14 This 38-item scale was later criticized for measuring irrelevant items, having redundancy, and lacking sensitivity.13,15 In developing instruments to measure obstetric patient satisfaction, others have used literature reviews and identified generic domains of patient satisfaction. Researchers then drafted items relevant to pregnancy and newborn care and pilot tested the surveys in a sample of women.16 These instruments are usually based on a psychometric approach to studying patient satisfaction, in which responses to multiple questions are combined into aggregate scores and given such names as the ‘‘art of care,’’ or ‘‘technical quality of care.’’ A problem with this traditional approach is that it typically affords patients the opportunity to answer items only in a structured questionnaire format and does not give attention to the full scope of a patient’s specific values and beliefs. This problem is even more pronounced in the obstetric literature, where the domains often do not reflect important patient-centered attributes associated with patient satisfaction. In fact, much of this research has been criticized for using ‘‘forced-choice’’ questionnaires that fail to identify important components of the birth experience.17 In addition, the majority of studies can overestimate levels of satisfaction because the commonly used Likerttype scales tend to elicit fewer negative responses than open-ended questions. These approaches may also limit the range and complexity of responses.13 An alternative or supplemental methodologic approach to patient satisfaction begins by giving patients an unconstrained opportunity to describe the importance and scope of their own reactions. The raw descriptions are then organized, according to similar themes, into specific attributes and categories. This type of clinimetric strategy18 has been previously used to assess patient satisfaction in both inpatient19 and outpatient20 nonobstetric settings. Although a few studies in obstetrics have used open-ended questions in the development of survey instruments, they have not used a clinimetric approach to measure patient satisfaction in the postpartum hospital setting. For example, in one study16 the investigators first designed a survey and then convened a focus group to review and comment on the survey instrument. Participants were asked to comment on the
Howell and Concato already existing instrument rather than express unrestricted opinions about obstetric care. In addition, the focus group participants were randomly selected female enrollees of a managed care plan rather than actual postpartum patients. The current research was performed to apply clinimetric methods for assessing patient satisfaction in a postpartum hospital setting. The goal of the study was to let the remarks made by patients, rather than the fixed, predetermined items of a psychometric instrument, be the source of a taxonomy for classifying patient satisfaction in the postpartum hospital setting. The clinimetric approach allows patients the opportunity to specify important features of their satisfaction and dissatisfaction with care and would also produce results that are clinically sensible and immediately interpretable by clinicians and policy makers.
Material and methods After obtaining approval from our institutional review board and acquiring oral consent from participants, we conducted in-person interviews at YaleeNew Haven Hospital during a 3-month period in 1999. YaleeNew Haven Hospital is the major academic center in the greater New Haven region and has elements of a tertiary referral center as well as a primary care community hospital. Women were eligible if they were delivered at YaleeNew Haven Hospital, spoke English, and were aged 18 years or older. A convenience sample was recruited by identifying patients through census logs on the postpartum floors and approaching patients two or three mornings a week (based on the availability of the first author) during the enrollment period. We developed an interview guide that included a standard script of open-ended questions constructed to determine patient likes and dislikes regarding the care they received while in the hospital for the delivery of their children. Similar open-ended questions have been validated in both inpatient hospital settings19 and outpatient primary care settings.20 Specifically, we asked patients, ‘‘what things did you like.,’’ ‘‘what things did you dislike.,’’ and ‘‘what things would you like to have changed.’’ (or ‘‘kept the same.’’) about the in-hospital obstetric experience? We also asked patients, ‘‘are there any things that are important to you what were handled well’’ and ‘‘are there any things that are important to you that were handled badly?’’ In addition to these six questions, patients were also asked to rate the overall quality of care they received on a 10-point scale, with 0 being the worst and 10 being the best. The same script of open-ended questions was asked of all participants, and the first author conducted all interviews. Other than requests to clarify responses, no follow-up questions were asked. The interview also
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Howell and Concato contained questions on demographic factors, including age, insurance type, gravidity, parity, marital status, and race. Medical records were reviewed for infants’ Apgar scores, gestational age at delivery, and hospital course. Patients’ responses were transcribed by the primary author during each interview. Next, comments were computerized and printed. Responses were reviewed and analyzed for themes by two independent reviewers of the data. After individual comments of patients were transcribed and assembled, comments with similar themes were arranged into a list of distinct ‘‘items’’ (variables) that directly reflected patients’ responses. The items were then assembled, based on a consensus of the two authors, into pertinent ‘‘categories’’ and ‘‘axes,’’ and organized as a taxonomy of patient satisfaction in the postpartum hospital setting. This task involved using the investigators’ clinical judgment to assemble each item within the categories and axes of related phenomena, as shown in the Results section. All descriptive statistics were calculated with Microsoft Excel (Microsoft, Seattle, Wash).
Results Among the 73 patients screened during the enrollment period, 5 were ineligible (3 patients were less than 18 years old and 2 patients did not speak English). Among the 68 eligible women approached during the enrollment period, 1 patient refused to participate, for a response rate of 99%. Patient demographic and delivery information for the 67 patients included in this study is presented in Table I. The women in this study had a mean age of 31 years and a mean parity of 2. Most of the patients were white (67%), married (79%), and had a health management organization (HMO) (75%) for health insurance coverage. The majority of patients were delivered vaginally, were term at delivery, and had infants with high 5-minute Apgar scores. Patients were treated by house staff and/or attending physicians from the Yale University School of Medicine. The mean overall satisfaction rating for the entire sample was 9.2 (0-10 scale). Patients were found to express their opinions freely. Raw responses were reviewed and the comments were arranged according to similarity of content. The authors then reached consensus on a specific list of items related to satisfaction. For example, two comments about the care their newborn infants receivedd‘‘nursery was good’’ and ‘‘.received quick competent response to needs of my baby after delivery’’dwere considered to represent the perceived quality of care regarding newborn care. Two comments about the location of the infant d‘‘like that we have the baby in the room’’ and ‘‘we didn’t like them taking the baby away’’dwere considered to represent the proximity of infant and mother (‘‘rooming in’’) aspect of newborn care. In addition, two comments about physical surroundingsd‘‘like that
Table I
Baseline characteristics of patients (n = 67)
Age (y) (mean) Gravidity (mean) Parity (mean) Gestational age (wk) (mean) 5-min Apgar score (mean) Race White African American Latina Asian Other Marital status Married Unmarried Widowed, divorced, or separated Health insurance Medicaid Health maintenance organization Private Type of delivery Vaginal delivery Cesarean section
31 (18-42) 2 (1-7) 2 (1-4) 39 (27-42) 9 (8-10) 45 (67.2) 12 (17.9) 6 (9.0) 3 (4.5) 1 (1.5) 53 (79.1) 12 (17.9) 2 (3.0) 10 (14.9) 50 (74.6) 7 (10.4) 51 (76.1) 16 (23.9)
Values are given as mean (range) or number (%).
the husband can stay’’ and ‘‘need better recliners for husbands’’dwere considered to represent comfort for partner. After suitably organizing the variables, the overall taxonomy of patient satisfaction was divided into six main axes of classification, describing characteristics of (1) physicians, (2) nurses, (3) other staff, (4) services, (5) hospital attributes, and (6) issues related to ‘‘personal focus.’’ Each of these main axes included several categories, with or without subcategories; and each contained the specific items or variables that emerged from the raw data. For example, patients’ comments about accessibility and adequacy of postpartum pain management were combined in a satisfaction category called postdelivery pain management. The taxonomy is outlined in Table II and is described in greater detail and exemplified with direct quotations in the Appendix. A total of 51 items were identified related to patient satisfaction. Attributes of physicians included 10 items, such as competence, knowledge, and communication skills. Eight attributes of nurses were identified, including items such as competence, accessibility, and supportiveness; and three attributes of other staff were identified. Thirteen attributes of specific services were identified, including items such as anesthesia accessibility, postdelivery pain management, proximity of the newborn infant, timing of feedings, infant security, maternal infant bonding, and breast-feeding education. Ten hospital attributes were identified, such as family friendly atmosphere, housekeeping, and quality of food. Personal focus included seven items that reflected the personal perspectives of patients, including their preferences
178 Table II Taxonomy of components of patient satisfaction in obstetric postpartum patients 1. Physician staff 1.1 Professionalism 1.1.1 Competence 1.1.2 Knowledge 1.1.3 Communication 1.1.4 Experience 1.2 Availability 1.2.1 Accessibility 1.2.2 Timeliness 1.3 Personal style 1.3.1 Attentiveness to patient’s concerns 1.3.2. Compassion/Sensitivity 1.3.3 Reinforcement 1.4 Teamwork 1.4.1 Uniform information or recommendations 2. Nursing staff 2.1 Professionalism 2.1.1 Competence 2.1.2 Knowledge 2.1.3 Communication 2.2 Availability 2.2.1 Accessibility 2.2.2 Timeliness 2.3 Personal Style 2.3.1 Support 2.3.2 Friendliness 2.3.3 Sensitivity 3. Other staff 3.1 Performance 3.2 Availability 3.3 Personal Style 4. Services 4.1 Anesthesia (epidural) 4.1.1 Accessibility 4.1.2 Timeliness 4.1.3 Proficiency 4.2 Postdelivery pain management 4.2.1 Accessibility 4.2.2 Adequacy 4.3 Newborn care 4.3.1 Perceived quality of care 4.3.2 Proximity of infant and mother (‘‘rooming in’’) 4.3.3 Timing of feedings 4.3.4 Security 4.3.5 Maternal infant bonding 4.4 Breast-feeding 4.4.1 Education 4.4.2 Support 4.4.3 Attitude 4.5 Discharge preparation (beyond scope of this project) 5. Hospital attributes 5.1 Administrative services 5.1.1 Perceived overall quality of care 5.1.2 Efficiency 5.1.3 Family oriented focus
Howell and Concato Table II
(continued)
5.2 Physical surroundings 5.2.1 Aesthetics 5.2.2 Comfort for patient 5.2.3 Comfort for partner 5.2.4 Cleanliness 5.2.5 Parking 5.3 Institutional food 5.3.1 Variety 5.3.2 Quality 6. Personal focus 6.1 Overall experience of pain 6.2 Positive affirmation of birthing process 6.3 Feeling understood 6.4 Respect for preferences 6.5 Privacy 6.6 Choice among options 6.7 Other
being respected, having choices and options, and feeling understood. Although the current study was not intended to produce quantitative results, some general findings can be reported. For example, the three most frequent ‘‘likes’’ among women were support from nurses, friendliness of nurses, and infants rooming in. In contrast, the top three reported ‘‘dislikes’’ were pain (overall experience), proficiency of the epidural, and quality of food.
Comment We used a clinimetric approach of asking open-ended questions to women during their postpartum hospital stays and developed a taxonomy of patient satisfaction for obstetric inpatients. Six simple open-ended questions were used to determine important attributes of patient satisfaction in this setting. Unlike many of the existing instruments developed to assess patient satisfaction in obstetrics, we used the responses of actual postpartum patients to develop a taxonomy of patient satisfaction. Our approach produced a broad description of patient satisfaction in the postpartum setting. This research was undertaken because of a fundamental belief that postpartum obstetric patients are the best judges of their satisfaction with care. We constructed our taxonomy according to face validityda statistically unmeasurable concept of an instrument’s ‘‘common sense’’ in doing its intended task. The transparency of results is evident in the category of physician personal style, containing attentiveness to patient’s concerns, compassion, and reinforcement; these attributes seem more clinically obvious and direct than the psychometric calculation of a derived factor representing physicians’ overall ‘‘humaneness.’’21 In addition, our method allowed us to better understand the full
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Howell and Concato scope of patient likes and dislikes, and therefore our taxonomy includes a broad spectrum of attributes that help to define patient satisfaction in obstetrics. Many of the current studies of patient satisfaction in obstetrics are based on instruments developed for nonobstetric patients and therefore do not include many of the items postpartum obstetric patients value.22 For example, in one recent article23 investigating patient assessments of maternity care, postpartum patients were mailed questionnaires 8 to 12 weeks post partum and asked to use 4- or 5-point scales to evaluate the care they received from their physicians and nurses, and also to give a global assessment of care. The questionnaire assessed six items on physician care, five items on nursing care, and three items on global assessment of care, but none of the items were specific to the experiences of obstetric patients; and no items on breast-feeding, newborn care, or ‘‘personal focus’’ were included in their survey. Our research suggests that many additional categories should be included in the assessment of patient satisfaction in the postpartum setting. Although our study is limited by a relatively small sample size and a population from a single institution, its strength lies in the conduct of open-ended personal interviews. The open-ended questions allowed patients to express the full scope of their feelings and reactions to the questions asked, and we reached theme saturation24 by the end of the study. In addition, we interviewed patients very proximate to the time of their delivery, when they are likely to have the most relevant basis to describe their experience (both positive and negative) regarding labor and delivery. (In particular, their responses are not subject to recall bias.) The timing of our interview, however, did not allow us to address issues related to discharge preparation or length of hospital stay. In contrast to other studies, we allowed patients, not a preexisting instrument, to dictate the domains of patient satisfaction for this sample of patients. We did not, however, use any methods to evaluate the relative importance of individual attributes in our patient satisfaction taxonomy. Our goal was to allow patients to specify the important features of their satisfaction with care; the next step in this line of research would be to measure, in a larger sample of patients, the relative value of different domains. Our study can be considered part of a process of improving strategies for measuring patient satisfaction in obstetrics. Our new taxonomy and the corresponding clinimetric approach of asking open-ended questions can be used in at least three ways. First, for administrative (eg, quality assurance) purposes, the open-ended questions can sometimes replace more complex surveys of patient satisfaction. A simple review of patients’ responses would be understandable to clinicians and policymakers. In addition, if the results are organized according to the new taxonomy, repeated surveys can
establish trends for specific items of patient satisfaction over time. Second, for research, the clinimetric questionnaire can be compared with other existing psychometric instruments, such as the Labor and Delivery Satisfaction Index. The comparison will determine whether similar attributes of patient satisfaction are identified by each instrument. Third, for medical education, the 10 items in axis 1 (physicians) of the taxonomy can be used directly, by students or their teachers, as a checklist of provider-specific aspects of postpartum inpatient care that are important to patients. For example, the items may be considered by attending physicians when observing medical students or house staff during a patient encounter in the postpartum hospital setting. In conclusion, our clinimetric approach to measure patient satisfaction in the postpartum inpatient setting produced a clinically relevant taxonomy and has the advantage of giving results that are clearly understood and comprehensive. This simple instrument uses relatively few questions to identify a broad scope of patient satisfaction in the postpartum setting.
References 1. Derose KP, Hays RD, McCaffrey DF, Baker DW. Does physician gender affect satisfaction of men and women visiting the emergency department? J Gen Intern Med 2001;16:218-26. 2. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med 1992;15:447-68. 3. Marquis MS, Davies AR, Ware JE Jr. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care 1983;21:821-9. 4. Ware JE Jr, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann 1983;6: 291-7. 5. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282: 583-9. 6. Hall JA, Roter DL. Patient gender and communication with physicians: results of a community-based study. Womens Health 1995;1:77-95. 7. Howell EA, Gardiner B, Concato J. Do women prefer female obstetricians? Obstet Gynecol 2002;99:1031-5. 8. Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP Jr. Effect of physician and patient gender concordance on patient satisfaction and preventive care practices. J Gen Intern Med 2000;15:761-9. 9. Light HK, Solheim JS, Hunter GW. Satisfaction with medical care during pregnancy and delivery. Am J Obstet Gynecol 1975;125: 827-31. 10. Luley J. Assessing satisfaction with childbirth. Birth 1985;12:141-5. 11. Sullivan DA, Beeman R. Satisfaction with maternity care: a matter of communication and choice. Med Care 1982;20:321-30. 12. Kirke PN. Mother’s views of care in labour. BJOG 1980;87:1034-8. 13. Bramadat IJ, Driedger M. Satisfaction with childbirth: theories and methods of measurement. Birth 1993;20:22-9. 14. Lomas J, Dore S, Enkin M, Mitchell A. The Labor and Delivery Satisfaction Index: the development and evaluation of a soft outcome measure. Birth 1987;14:125-9. 15. Shearer MH. Commentary: How well does the LADSI measure satisfaction with labor and delivery? Birth 1987;14:130-1.
180 16. Lawrence JM, Ershoff D, Mendez C, Petitti DB. Satisfaction with pregnancy and newborn care: development and results of a survey in a health maintenance organization. Am J Manag Care 1995;5: 1407-13. 17. Wilcock A, Kobayashi L, Murray I. Twenty-five years of obstetric patient satisfaction in North America: a review of the literature. J Perinat Neonat Nurs 1997;10:36-47. 18. Feinstein AR. Clinimetrics. New Haven (CT): Yale University Press; 1987. 19. Matthews DA, Feinstein AR. A new instrument for patients’ ratings of physician performance in the hospital setting. J Gen Intern Med 1989;4:14-22. 20. Concato J, Feinstein AR. Asking patients what they like: overlooked attributes of patient satisfaction with primary care. Am J Med 1997;102:399-406. 21. Yano EM, Fink A, Graham M. Patient satisfaction with ambulatory care in general and subspecialty clinics. Sepulveda (CA): 1993. PACE Evaluation Monograph Series VA-S 93101. 22. Finkelstein BS, Singh J, Silvers JB, Neuhaser D, Rosenthal GE. Patient and hospital characteristics associated with patient assessments of hospital obstetrical care. Med Care 1998;36: AS68-78. 23. Finkelstein BS, Harper DL, Rosenthal G. Patient assessments of hospital maternity care: a useful tool for consumers. Health Serv Res 1999;34:623-40. 24. Strauss AL, Corbin JM. Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks (CA): Sage Publications; 1998.
Appendix 1. Physician Staff. Comments about physicians were subclassified in categories of: professionalism, availability, personal style, and teamwork. 1.1. Professionalism. Professionalism was divided into competence, knowledge, communication, and experience. 1.1.1. Competence. Patients acknowledged physicians’ skills and qualities with comments such as ‘‘they were excellent’’ and ‘‘. I was in good hands.’’ 1.1.2. Knowledge. Patients emphasized physician’s knowledge with remarks such as ‘‘they know what they are doing.’’ 1.1.3. Communication. Patients spoke about the importance of communication with remarks such as ‘‘.kept me well informed; they answered my questions.’’ Patients also expressed frustrations with lack of communication: ‘‘couple of things were not explained; .wish I had been more educated about the actual delivery.’’ 1.1.4. Experience. Patients emphasized the experience of their physicians: ‘‘her labor and delivery experience.’’ 1.2. Availability. Availability was divided into accessibility and timeliness. 1.2.1. Accessibility. Patients liked accessible physicians: ‘‘there are many doctors checking on me and my baby frequently’’ and patients disliked inaccessible physicians: ‘‘lack of interaction with doctors.’’ 1.2.2. Timeliness. This attribute was categorized favorably: ‘‘doctor responded quickly.’’
Howell and Concato 1.3. Personal style. Physicians’ personal style was mentioned as attentiveness to patient’s concerns, compassion/sensitivity, and reinforcement. 1.3.1. Attentiveness to patient’s concerns. Patients appreciate attentive physicians: ‘‘very attentive.’’ 1.3.2. Compassion/sensitivity. Compassion and sensitivity were important attributes in physicians: ‘‘I was scared about having a c-section, everyone made me feel real comfortable,’’ ‘‘.listened to me, took time with me.’’ 1.3.3. Reinforcement. Patients appreciated physicians who gave them reinforcement: ‘‘made me feel secure; reassured me; made sure we understood, made sure we were comfortable with the situation.’’ 1.4. Teamwork. A coordinated effort by attending physicians and residents was important to patients. 1.4.1. Uniform information or recommendations: ‘‘doctors need to get together.they said different things to me; within my obstetrics/gynecology group, doctors had different philosophies regarding anesthesia.this made me apprehensive.’’ 2. Nursing Staff. Patients emphasized the role of nurses in their labor and delivery experience and their postpartum experience. Comments about nurses were subclassified in categories of: professionalism, availability, and personal style. 2.1. Professionalism. Professionalism was divided into competence, knowledge, and communication. 2.1.1. Competence. Patients acknowledged nurses’ skills and qualities with descriptions such as ‘‘well-trained nurses.’’ 2.1.2. Knowledge. Patients emphasized nurse’s knowledge with remarks such as ‘‘nurses were informative; knowledgeable.’’ 2.1.3. Communication. Patients spoke about the importance of communication with remarks such as ‘‘.explained everything; explaining and teaching important to .staff.’’ 2.2. Availability. Availability was divided into accessibility and timeliness. 2.2.1. Accessibility. Patients liked accessible nurses: ‘‘when I pressed the button the nurses came.answered my questions for my baby and my personal care; a nurse was with me at all times.’’ 2.2.2. Timeliness. This attribute was important to patients: ‘‘ask for things and it took forever; change of shifts is tough on patients.’’ 2.3. Personal style. Nurses’ personal style was mentioned as support, friendliness, and sensitivity. 2.3.1. Support. Patients emphasized the support they received from the nurses: ‘‘supportive, helpful, patient, encouraging.’’ 2.3.2. Friendliness. Patients described nurses as ‘‘friendly, wonderful.’’ 2.3.3. Sensitivity. Patients described nurses as: ‘‘attentive, responsive to my needs, answered questions.’’
Howell and Concato 3. Other Staff. Other staff included staff other than physicians and nurses. Comments about other staff were divided into comments about performance, availability, and personal style. 3.1. Performance. Other staff were described as ‘‘good.’’ 3.2. Availability. Other staff were described as ‘‘understaffed, no assistants, no aids, no one in admitting when we came in.’’ 3.3. Personal style. Other staff were also described as ‘‘nice; accommodating.’’ 4. Services. The open-ended questions elicited comments on services. Services were divided into anesthesia, post delivery pain management, newborn care, and breastfeeding. 4.1. Anesthesia (epidural). Anesthesia was cited as an important service. Three important attributes of anesthesia were accessibility, timeliness, and proficiency. 4.1.1. Accessibility. Patients emphasized the importance of pain management during labor: ‘‘epidural was great.’’ 4.1.2. Timeliness. Patients also emphasized wanting the epidural in a timely fashion: ‘‘epidural should be placed sooner; anesthesiologist took a long time.’’ 4.1.3. Proficiency. Patients remarked about whether their epidural worked with comments such as: ‘‘the epidural didn’t work’’ and ‘‘they had to put it (the epidural) twice.’’ 4.2. Postdelivery pain management. Patients emphasized the importance of postdelivery pain management and this was divided into accessibility and adequacy. 4.2.1. Accessibility. Patients remarked ‘‘they didn’t ask me about pain meds, I didn’t know I should ask.’’ 4.2.2. Adequacy. Patients also remarked ‘‘post partum I had to keep calling for pain meds.’’ 4.3. Newborn care. Newborn care was an important service that patients identified. It was divided into perceived quality of care, location, feedings, security, and maternal infant bonding. 4.3.1. Perceived quality of care. Patients noted ‘‘nursery was good; quick competent response to needs of my baby after delivery.’’ 4.3.2. Proximity. Patients commented about having the baby in the room with them after delivery: ‘‘like that we have the baby in the room’’ and ‘‘we didn’t like them taking the baby away.’’ 4.3.3. Timing of feedings. Patients also were concerned regarding the timing of feedings: ‘‘different opinions abut feeding the baby during the night.’’ 4.3.4. Security. Patients wanted to feel that their children were ‘‘safe.’’ 4.3.5. Maternal infant bonding. Having time to immediately bond with the baby was also important to women: ‘‘the baby came to me immediately after delivery; I had enough time holding her after delivery, they were very sensitive to this, I didn’t feel rushed.’’ 4.4. Breast-feeding. Breast-feeding was an important aspect of patient satisfaction and was subdivided into education, support, and attitude.
181 4.4.1. Education. Patients noted: ‘‘staff very helpful with breast-feeding; like to stay longer in the hospital to have more coaching on breast-feeding; all my questions handled extremely well.’’ 4.4.2. Support. Patients remarked: ‘‘need more breastfeeding support; everyone was right there, a nurse was with me at all times.’’ 4.4.3. Attitude: Patients also noted that many staff had strong opinions about breast-feeding: ‘‘too forceful with breast-feeding.’’ 4.5. Discharge preparation (beyond scope of this project). Interviews occurred before patients received discharge instructions. 5. Hospital attributes. Various aspects of the hospital were included as sources of patients’ satisfaction. 5.1. Administrative services. Administrative services evoked comments about perceived overall quality of care, efficiency, and family oriented focus. 5.1.1. Perceived overall quality of care. For example, ‘‘Overall the system works well; the whole labor and delivery staff was extraordinary.’’ 5.1.2. Efficiency. Patients remarked positively and negatively about efficiency of the hospital: ‘‘efficient; pretty easy, smooth’’ and ‘‘it took forever.’’ 5.1.3. Family oriented focus. Family friendly atmosphere was important to patients: ‘‘It was nice that they didn’t limit me to having just my husband, I had my niece and mother as well.’’ 5.2. Physical surroundings. Physical surroundings was subdivided into aesthetics, comfort for patient, comfort for partner, cleanliness, and parking. 5.2.1. Aesthetics. Rooms were described as ‘‘great rooms.’’ 5.2.2. Comfort for patient. Patients noted their comfort: ‘‘disliked the bed, very uncomfortable.’’ 5.2.3. Comfort for partner. Patients also noted their partner’s comfort: ‘‘like that the husband can stay; need better recliners for husbands.’’ 5.2.4. Cleanliness. Cleanliness was important to patients: ‘‘didn’t change the sheets enough; want cleaner room.’’ 5.2.5. Parking. Patients also noted parking: ‘‘When I came to the ER there was a problem with parking. should be smoother.’’ 5.3. Institutional food. Attributes of food were divided into variety and quality. 5.3.1. Variety. Patients remarked: ‘‘need more variety.’’ 5.3.2. Quality. Patients also commented: ‘‘food was great; food was terrible.’’ 6. Personal focus. Patients emphasized an inward focus about their delivery experience and this was divided into: overall experience of pain, positive affirmation of birthing process, feeling understood, having their preferences respected, privacy, choice, and other. 6.1. Overall experience of pain. Patients complained about childbirth-associated pain with general statements such as ‘‘The pain.can’t say much about this, nothing to do with the hospital itself that I disliked.’’
182 6.2. Positive affirmation of birthing process. Patients remarked that throughout the process they received positive affirmation from the staff and they were ‘‘enthusiastic,’’ ‘‘supportive,’’ and ‘‘reassuring.’’ 6.3. Feeling understood. Patients wanted to feel understood: ‘‘they were understanding.’’ 6.4. Preferences respected. Patients wanted their preferences respected: ‘‘receptive to my wishes, my wishes were honored.’’
Howell and Concato 6.5. Privacy. Patients commented on the lack of privacy: ‘‘no privacy.’’ 6.6. Choice. Patients wanted choice and options: ‘‘.got a choice for elective induction; make my own choice (for pain management during delivery).’’ 6.7. Other. The final category was other, which included support network for moms: ‘‘Mom’s support networkd nothing done to bring moms together.’’
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Obstetric patient satisfaction: Asking patients what they like Elizabeth A. Howell, MD, MPP,* John Concato, MD, MPH Departments of Obstetrics and Gynecology and Health Policy, Mount Sinai Medical Center, the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New York, NY, and the Clinical Epidemiology Research Center, West Haven Veterans Affairs Medical Center, New Haven and West Haven, Conn Received for publication March 17, 2003; revised June 2, 2003; accepted June 10, 2003
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Obstetrics Patient satisfaction
Objective: This study was undertaken to determine pertinent attributes of women’s hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics. Study design: By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction. Results: The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction. Conclusion: A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services. Ó 2004 Elsevier Inc. All rights reserved.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Patient satisfaction has received a great deal of attention in the medical literature and is an important indicator of quality of care.1 In addition, as various health
Supported by a fellowship in the Robert Wood Johnson Clinical Scholars Program at Yale University (E. H.). The opinions, view, and conclusions expressed in this article are those of the authors and not necessarily those of the Robert Wood Johnson Foundation. * Reprint requests: Elizabeth Howell, MD, MPP, Department of Health Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1077, New York, NY 10029-6574. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2003.06.006
plans compete to provide care for groups of patients, much attention has been focused on patient satisfaction as a way to attract and retain patients. Studies have shown that satisfied patients tend to be more adherent to medical recommendations2 and less likely to ‘‘physician shop’’ or disenroll from health plans.1,3,4 Studies on patient satisfaction vary widely, ranging from evaluation of health-related programs, performance of health care providers, to factors that may influence patient satisfaction such as physician gender and patient preferences.5-8 Researchers have investigated the topic of patient satisfaction in the field of obstetrics since the 1970s.9,10
176 Much of the early work examined factors associated with satisfaction rather than clearly defining the underlying construct of patient satisfaction in obstetrics.11 In addition, many of the instruments used were simple measures of satisfaction, with women often asked to rate their experience on a single-item scale (eg, women’s willingness to return to the same hospital for subsequent births was considered an assessment of satisfaction).12,13 Later work shifted to developing tools to measure patient satisfaction. For example, investigators in the late 1980s developed scales to measure important ‘‘soft outcomes’’ of childbirth, with instruments such as the Labor and Delivery Satisfaction Index.14 This 38-item scale was later criticized for measuring irrelevant items, having redundancy, and lacking sensitivity.13,15 In developing instruments to measure obstetric patient satisfaction, others have used literature reviews and identified generic domains of patient satisfaction. Researchers then drafted items relevant to pregnancy and newborn care and pilot tested the surveys in a sample of women.16 These instruments are usually based on a psychometric approach to studying patient satisfaction, in which responses to multiple questions are combined into aggregate scores and given such names as the ‘‘art of care,’’ or ‘‘technical quality of care.’’ A problem with this traditional approach is that it typically affords patients the opportunity to answer items only in a structured questionnaire format and does not give attention to the full scope of a patient’s specific values and beliefs. This problem is even more pronounced in the obstetric literature, where the domains often do not reflect important patient-centered attributes associated with patient satisfaction. In fact, much of this research has been criticized for using ‘‘forced-choice’’ questionnaires that fail to identify important components of the birth experience.17 In addition, the majority of studies can overestimate levels of satisfaction because the commonly used Likerttype scales tend to elicit fewer negative responses than open-ended questions. These approaches may also limit the range and complexity of responses.13 An alternative or supplemental methodologic approach to patient satisfaction begins by giving patients an unconstrained opportunity to describe the importance and scope of their own reactions. The raw descriptions are then organized, according to similar themes, into specific attributes and categories. This type of clinimetric strategy18 has been previously used to assess patient satisfaction in both inpatient19 and outpatient20 nonobstetric settings. Although a few studies in obstetrics have used open-ended questions in the development of survey instruments, they have not used a clinimetric approach to measure patient satisfaction in the postpartum hospital setting. For example, in one study16 the investigators first designed a survey and then convened a focus group to review and comment on the survey instrument. Participants were asked to comment on the
Howell and Concato already existing instrument rather than express unrestricted opinions about obstetric care. In addition, the focus group participants were randomly selected female enrollees of a managed care plan rather than actual postpartum patients. The current research was performed to apply clinimetric methods for assessing patient satisfaction in a postpartum hospital setting. The goal of the study was to let the remarks made by patients, rather than the fixed, predetermined items of a psychometric instrument, be the source of a taxonomy for classifying patient satisfaction in the postpartum hospital setting. The clinimetric approach allows patients the opportunity to specify important features of their satisfaction and dissatisfaction with care and would also produce results that are clinically sensible and immediately interpretable by clinicians and policy makers.
Material and methods After obtaining approval from our institutional review board and acquiring oral consent from participants, we conducted in-person interviews at YaleeNew Haven Hospital during a 3-month period in 1999. YaleeNew Haven Hospital is the major academic center in the greater New Haven region and has elements of a tertiary referral center as well as a primary care community hospital. Women were eligible if they were delivered at YaleeNew Haven Hospital, spoke English, and were aged 18 years or older. A convenience sample was recruited by identifying patients through census logs on the postpartum floors and approaching patients two or three mornings a week (based on the availability of the first author) during the enrollment period. We developed an interview guide that included a standard script of open-ended questions constructed to determine patient likes and dislikes regarding the care they received while in the hospital for the delivery of their children. Similar open-ended questions have been validated in both inpatient hospital settings19 and outpatient primary care settings.20 Specifically, we asked patients, ‘‘what things did you like.,’’ ‘‘what things did you dislike.,’’ and ‘‘what things would you like to have changed.’’ (or ‘‘kept the same.’’) about the in-hospital obstetric experience? We also asked patients, ‘‘are there any things that are important to you what were handled well’’ and ‘‘are there any things that are important to you that were handled badly?’’ In addition to these six questions, patients were also asked to rate the overall quality of care they received on a 10-point scale, with 0 being the worst and 10 being the best. The same script of open-ended questions was asked of all participants, and the first author conducted all interviews. Other than requests to clarify responses, no follow-up questions were asked. The interview also
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Howell and Concato contained questions on demographic factors, including age, insurance type, gravidity, parity, marital status, and race. Medical records were reviewed for infants’ Apgar scores, gestational age at delivery, and hospital course. Patients’ responses were transcribed by the primary author during each interview. Next, comments were computerized and printed. Responses were reviewed and analyzed for themes by two independent reviewers of the data. After individual comments of patients were transcribed and assembled, comments with similar themes were arranged into a list of distinct ‘‘items’’ (variables) that directly reflected patients’ responses. The items were then assembled, based on a consensus of the two authors, into pertinent ‘‘categories’’ and ‘‘axes,’’ and organized as a taxonomy of patient satisfaction in the postpartum hospital setting. This task involved using the investigators’ clinical judgment to assemble each item within the categories and axes of related phenomena, as shown in the Results section. All descriptive statistics were calculated with Microsoft Excel (Microsoft, Seattle, Wash).
Results Among the 73 patients screened during the enrollment period, 5 were ineligible (3 patients were less than 18 years old and 2 patients did not speak English). Among the 68 eligible women approached during the enrollment period, 1 patient refused to participate, for a response rate of 99%. Patient demographic and delivery information for the 67 patients included in this study is presented in Table I. The women in this study had a mean age of 31 years and a mean parity of 2. Most of the patients were white (67%), married (79%), and had a health management organization (HMO) (75%) for health insurance coverage. The majority of patients were delivered vaginally, were term at delivery, and had infants with high 5-minute Apgar scores. Patients were treated by house staff and/or attending physicians from the Yale University School of Medicine. The mean overall satisfaction rating for the entire sample was 9.2 (0-10 scale). Patients were found to express their opinions freely. Raw responses were reviewed and the comments were arranged according to similarity of content. The authors then reached consensus on a specific list of items related to satisfaction. For example, two comments about the care their newborn infants receivedd‘‘nursery was good’’ and ‘‘.received quick competent response to needs of my baby after delivery’’dwere considered to represent the perceived quality of care regarding newborn care. Two comments about the location of the infant d‘‘like that we have the baby in the room’’ and ‘‘we didn’t like them taking the baby away’’dwere considered to represent the proximity of infant and mother (‘‘rooming in’’) aspect of newborn care. In addition, two comments about physical surroundingsd‘‘like that
Table I
Baseline characteristics of patients (n = 67)
Age (y) (mean) Gravidity (mean) Parity (mean) Gestational age (wk) (mean) 5-min Apgar score (mean) Race White African American Latina Asian Other Marital status Married Unmarried Widowed, divorced, or separated Health insurance Medicaid Health maintenance organization Private Type of delivery Vaginal delivery Cesarean section
31 (18-42) 2 (1-7) 2 (1-4) 39 (27-42) 9 (8-10) 45 (67.2) 12 (17.9) 6 (9.0) 3 (4.5) 1 (1.5) 53 (79.1) 12 (17.9) 2 (3.0) 10 (14.9) 50 (74.6) 7 (10.4) 51 (76.1) 16 (23.9)
Values are given as mean (range) or number (%).
the husband can stay’’ and ‘‘need better recliners for husbands’’dwere considered to represent comfort for partner. After suitably organizing the variables, the overall taxonomy of patient satisfaction was divided into six main axes of classification, describing characteristics of (1) physicians, (2) nurses, (3) other staff, (4) services, (5) hospital attributes, and (6) issues related to ‘‘personal focus.’’ Each of these main axes included several categories, with or without subcategories; and each contained the specific items or variables that emerged from the raw data. For example, patients’ comments about accessibility and adequacy of postpartum pain management were combined in a satisfaction category called postdelivery pain management. The taxonomy is outlined in Table II and is described in greater detail and exemplified with direct quotations in the Appendix. A total of 51 items were identified related to patient satisfaction. Attributes of physicians included 10 items, such as competence, knowledge, and communication skills. Eight attributes of nurses were identified, including items such as competence, accessibility, and supportiveness; and three attributes of other staff were identified. Thirteen attributes of specific services were identified, including items such as anesthesia accessibility, postdelivery pain management, proximity of the newborn infant, timing of feedings, infant security, maternal infant bonding, and breast-feeding education. Ten hospital attributes were identified, such as family friendly atmosphere, housekeeping, and quality of food. Personal focus included seven items that reflected the personal perspectives of patients, including their preferences
178 Table II Taxonomy of components of patient satisfaction in obstetric postpartum patients 1. Physician staff 1.1 Professionalism 1.1.1 Competence 1.1.2 Knowledge 1.1.3 Communication 1.1.4 Experience 1.2 Availability 1.2.1 Accessibility 1.2.2 Timeliness 1.3 Personal style 1.3.1 Attentiveness to patient’s concerns 1.3.2. Compassion/Sensitivity 1.3.3 Reinforcement 1.4 Teamwork 1.4.1 Uniform information or recommendations 2. Nursing staff 2.1 Professionalism 2.1.1 Competence 2.1.2 Knowledge 2.1.3 Communication 2.2 Availability 2.2.1 Accessibility 2.2.2 Timeliness 2.3 Personal Style 2.3.1 Support 2.3.2 Friendliness 2.3.3 Sensitivity 3. Other staff 3.1 Performance 3.2 Availability 3.3 Personal Style 4. Services 4.1 Anesthesia (epidural) 4.1.1 Accessibility 4.1.2 Timeliness 4.1.3 Proficiency 4.2 Postdelivery pain management 4.2.1 Accessibility 4.2.2 Adequacy 4.3 Newborn care 4.3.1 Perceived quality of care 4.3.2 Proximity of infant and mother (‘‘rooming in’’) 4.3.3 Timing of feedings 4.3.4 Security 4.3.5 Maternal infant bonding 4.4 Breast-feeding 4.4.1 Education 4.4.2 Support 4.4.3 Attitude 4.5 Discharge preparation (beyond scope of this project) 5. Hospital attributes 5.1 Administrative services 5.1.1 Perceived overall quality of care 5.1.2 Efficiency 5.1.3 Family oriented focus
Howell and Concato Table II
(continued)
5.2 Physical surroundings 5.2.1 Aesthetics 5.2.2 Comfort for patient 5.2.3 Comfort for partner 5.2.4 Cleanliness 5.2.5 Parking 5.3 Institutional food 5.3.1 Variety 5.3.2 Quality 6. Personal focus 6.1 Overall experience of pain 6.2 Positive affirmation of birthing process 6.3 Feeling understood 6.4 Respect for preferences 6.5 Privacy 6.6 Choice among options 6.7 Other
being respected, having choices and options, and feeling understood. Although the current study was not intended to produce quantitative results, some general findings can be reported. For example, the three most frequent ‘‘likes’’ among women were support from nurses, friendliness of nurses, and infants rooming in. In contrast, the top three reported ‘‘dislikes’’ were pain (overall experience), proficiency of the epidural, and quality of food.
Comment We used a clinimetric approach of asking open-ended questions to women during their postpartum hospital stays and developed a taxonomy of patient satisfaction for obstetric inpatients. Six simple open-ended questions were used to determine important attributes of patient satisfaction in this setting. Unlike many of the existing instruments developed to assess patient satisfaction in obstetrics, we used the responses of actual postpartum patients to develop a taxonomy of patient satisfaction. Our approach produced a broad description of patient satisfaction in the postpartum setting. This research was undertaken because of a fundamental belief that postpartum obstetric patients are the best judges of their satisfaction with care. We constructed our taxonomy according to face validityda statistically unmeasurable concept of an instrument’s ‘‘common sense’’ in doing its intended task. The transparency of results is evident in the category of physician personal style, containing attentiveness to patient’s concerns, compassion, and reinforcement; these attributes seem more clinically obvious and direct than the psychometric calculation of a derived factor representing physicians’ overall ‘‘humaneness.’’21 In addition, our method allowed us to better understand the full
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Howell and Concato scope of patient likes and dislikes, and therefore our taxonomy includes a broad spectrum of attributes that help to define patient satisfaction in obstetrics. Many of the current studies of patient satisfaction in obstetrics are based on instruments developed for nonobstetric patients and therefore do not include many of the items postpartum obstetric patients value.22 For example, in one recent article23 investigating patient assessments of maternity care, postpartum patients were mailed questionnaires 8 to 12 weeks post partum and asked to use 4- or 5-point scales to evaluate the care they received from their physicians and nurses, and also to give a global assessment of care. The questionnaire assessed six items on physician care, five items on nursing care, and three items on global assessment of care, but none of the items were specific to the experiences of obstetric patients; and no items on breast-feeding, newborn care, or ‘‘personal focus’’ were included in their survey. Our research suggests that many additional categories should be included in the assessment of patient satisfaction in the postpartum setting. Although our study is limited by a relatively small sample size and a population from a single institution, its strength lies in the conduct of open-ended personal interviews. The open-ended questions allowed patients to express the full scope of their feelings and reactions to the questions asked, and we reached theme saturation24 by the end of the study. In addition, we interviewed patients very proximate to the time of their delivery, when they are likely to have the most relevant basis to describe their experience (both positive and negative) regarding labor and delivery. (In particular, their responses are not subject to recall bias.) The timing of our interview, however, did not allow us to address issues related to discharge preparation or length of hospital stay. In contrast to other studies, we allowed patients, not a preexisting instrument, to dictate the domains of patient satisfaction for this sample of patients. We did not, however, use any methods to evaluate the relative importance of individual attributes in our patient satisfaction taxonomy. Our goal was to allow patients to specify the important features of their satisfaction with care; the next step in this line of research would be to measure, in a larger sample of patients, the relative value of different domains. Our study can be considered part of a process of improving strategies for measuring patient satisfaction in obstetrics. Our new taxonomy and the corresponding clinimetric approach of asking open-ended questions can be used in at least three ways. First, for administrative (eg, quality assurance) purposes, the open-ended questions can sometimes replace more complex surveys of patient satisfaction. A simple review of patients’ responses would be understandable to clinicians and policymakers. In addition, if the results are organized according to the new taxonomy, repeated surveys can
establish trends for specific items of patient satisfaction over time. Second, for research, the clinimetric questionnaire can be compared with other existing psychometric instruments, such as the Labor and Delivery Satisfaction Index. The comparison will determine whether similar attributes of patient satisfaction are identified by each instrument. Third, for medical education, the 10 items in axis 1 (physicians) of the taxonomy can be used directly, by students or their teachers, as a checklist of provider-specific aspects of postpartum inpatient care that are important to patients. For example, the items may be considered by attending physicians when observing medical students or house staff during a patient encounter in the postpartum hospital setting. In conclusion, our clinimetric approach to measure patient satisfaction in the postpartum inpatient setting produced a clinically relevant taxonomy and has the advantage of giving results that are clearly understood and comprehensive. This simple instrument uses relatively few questions to identify a broad scope of patient satisfaction in the postpartum setting.
References 1. Derose KP, Hays RD, McCaffrey DF, Baker DW. Does physician gender affect satisfaction of men and women visiting the emergency department? J Gen Intern Med 2001;16:218-26. 2. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med 1992;15:447-68. 3. Marquis MS, Davies AR, Ware JE Jr. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care 1983;21:821-9. 4. Ware JE Jr, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann 1983;6: 291-7. 5. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282: 583-9. 6. Hall JA, Roter DL. Patient gender and communication with physicians: results of a community-based study. Womens Health 1995;1:77-95. 7. Howell EA, Gardiner B, Concato J. Do women prefer female obstetricians? Obstet Gynecol 2002;99:1031-5. 8. Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP Jr. Effect of physician and patient gender concordance on patient satisfaction and preventive care practices. J Gen Intern Med 2000;15:761-9. 9. Light HK, Solheim JS, Hunter GW. Satisfaction with medical care during pregnancy and delivery. Am J Obstet Gynecol 1975;125: 827-31. 10. Luley J. Assessing satisfaction with childbirth. Birth 1985;12:141-5. 11. Sullivan DA, Beeman R. Satisfaction with maternity care: a matter of communication and choice. Med Care 1982;20:321-30. 12. Kirke PN. Mother’s views of care in labour. BJOG 1980;87:1034-8. 13. Bramadat IJ, Driedger M. Satisfaction with childbirth: theories and methods of measurement. Birth 1993;20:22-9. 14. Lomas J, Dore S, Enkin M, Mitchell A. The Labor and Delivery Satisfaction Index: the development and evaluation of a soft outcome measure. Birth 1987;14:125-9. 15. Shearer MH. Commentary: How well does the LADSI measure satisfaction with labor and delivery? Birth 1987;14:130-1.
180 16. Lawrence JM, Ershoff D, Mendez C, Petitti DB. Satisfaction with pregnancy and newborn care: development and results of a survey in a health maintenance organization. Am J Manag Care 1995;5: 1407-13. 17. Wilcock A, Kobayashi L, Murray I. Twenty-five years of obstetric patient satisfaction in North America: a review of the literature. J Perinat Neonat Nurs 1997;10:36-47. 18. Feinstein AR. Clinimetrics. New Haven (CT): Yale University Press; 1987. 19. Matthews DA, Feinstein AR. A new instrument for patients’ ratings of physician performance in the hospital setting. J Gen Intern Med 1989;4:14-22. 20. Concato J, Feinstein AR. Asking patients what they like: overlooked attributes of patient satisfaction with primary care. Am J Med 1997;102:399-406. 21. Yano EM, Fink A, Graham M. Patient satisfaction with ambulatory care in general and subspecialty clinics. Sepulveda (CA): 1993. PACE Evaluation Monograph Series VA-S 93101. 22. Finkelstein BS, Singh J, Silvers JB, Neuhaser D, Rosenthal GE. Patient and hospital characteristics associated with patient assessments of hospital obstetrical care. Med Care 1998;36: AS68-78. 23. Finkelstein BS, Harper DL, Rosenthal G. Patient assessments of hospital maternity care: a useful tool for consumers. Health Serv Res 1999;34:623-40. 24. Strauss AL, Corbin JM. Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks (CA): Sage Publications; 1998.
Appendix 1. Physician Staff. Comments about physicians were subclassified in categories of: professionalism, availability, personal style, and teamwork. 1.1. Professionalism. Professionalism was divided into competence, knowledge, communication, and experience. 1.1.1. Competence. Patients acknowledged physicians’ skills and qualities with comments such as ‘‘they were excellent’’ and ‘‘. I was in good hands.’’ 1.1.2. Knowledge. Patients emphasized physician’s knowledge with remarks such as ‘‘they know what they are doing.’’ 1.1.3. Communication. Patients spoke about the importance of communication with remarks such as ‘‘.kept me well informed; they answered my questions.’’ Patients also expressed frustrations with lack of communication: ‘‘couple of things were not explained; .wish I had been more educated about the actual delivery.’’ 1.1.4. Experience. Patients emphasized the experience of their physicians: ‘‘her labor and delivery experience.’’ 1.2. Availability. Availability was divided into accessibility and timeliness. 1.2.1. Accessibility. Patients liked accessible physicians: ‘‘there are many doctors checking on me and my baby frequently’’ and patients disliked inaccessible physicians: ‘‘lack of interaction with doctors.’’ 1.2.2. Timeliness. This attribute was categorized favorably: ‘‘doctor responded quickly.’’
Howell and Concato 1.3. Personal style. Physicians’ personal style was mentioned as attentiveness to patient’s concerns, compassion/sensitivity, and reinforcement. 1.3.1. Attentiveness to patient’s concerns. Patients appreciate attentive physicians: ‘‘very attentive.’’ 1.3.2. Compassion/sensitivity. Compassion and sensitivity were important attributes in physicians: ‘‘I was scared about having a c-section, everyone made me feel real comfortable,’’ ‘‘.listened to me, took time with me.’’ 1.3.3. Reinforcement. Patients appreciated physicians who gave them reinforcement: ‘‘made me feel secure; reassured me; made sure we understood, made sure we were comfortable with the situation.’’ 1.4. Teamwork. A coordinated effort by attending physicians and residents was important to patients. 1.4.1. Uniform information or recommendations: ‘‘doctors need to get together.they said different things to me; within my obstetrics/gynecology group, doctors had different philosophies regarding anesthesia.this made me apprehensive.’’ 2. Nursing Staff. Patients emphasized the role of nurses in their labor and delivery experience and their postpartum experience. Comments about nurses were subclassified in categories of: professionalism, availability, and personal style. 2.1. Professionalism. Professionalism was divided into competence, knowledge, and communication. 2.1.1. Competence. Patients acknowledged nurses’ skills and qualities with descriptions such as ‘‘well-trained nurses.’’ 2.1.2. Knowledge. Patients emphasized nurse’s knowledge with remarks such as ‘‘nurses were informative; knowledgeable.’’ 2.1.3. Communication. Patients spoke about the importance of communication with remarks such as ‘‘.explained everything; explaining and teaching important to .staff.’’ 2.2. Availability. Availability was divided into accessibility and timeliness. 2.2.1. Accessibility. Patients liked accessible nurses: ‘‘when I pressed the button the nurses came.answered my questions for my baby and my personal care; a nurse was with me at all times.’’ 2.2.2. Timeliness. This attribute was important to patients: ‘‘ask for things and it took forever; change of shifts is tough on patients.’’ 2.3. Personal style. Nurses’ personal style was mentioned as support, friendliness, and sensitivity. 2.3.1. Support. Patients emphasized the support they received from the nurses: ‘‘supportive, helpful, patient, encouraging.’’ 2.3.2. Friendliness. Patients described nurses as ‘‘friendly, wonderful.’’ 2.3.3. Sensitivity. Patients described nurses as: ‘‘attentive, responsive to my needs, answered questions.’’
Howell and Concato 3. Other Staff. Other staff included staff other than physicians and nurses. Comments about other staff were divided into comments about performance, availability, and personal style. 3.1. Performance. Other staff were described as ‘‘good.’’ 3.2. Availability. Other staff were described as ‘‘understaffed, no assistants, no aids, no one in admitting when we came in.’’ 3.3. Personal style. Other staff were also described as ‘‘nice; accommodating.’’ 4. Services. The open-ended questions elicited comments on services. Services were divided into anesthesia, post delivery pain management, newborn care, and breastfeeding. 4.1. Anesthesia (epidural). Anesthesia was cited as an important service. Three important attributes of anesthesia were accessibility, timeliness, and proficiency. 4.1.1. Accessibility. Patients emphasized the importance of pain management during labor: ‘‘epidural was great.’’ 4.1.2. Timeliness. Patients also emphasized wanting the epidural in a timely fashion: ‘‘epidural should be placed sooner; anesthesiologist took a long time.’’ 4.1.3. Proficiency. Patients remarked about whether their epidural worked with comments such as: ‘‘the epidural didn’t work’’ and ‘‘they had to put it (the epidural) twice.’’ 4.2. Postdelivery pain management. Patients emphasized the importance of postdelivery pain management and this was divided into accessibility and adequacy. 4.2.1. Accessibility. Patients remarked ‘‘they didn’t ask me about pain meds, I didn’t know I should ask.’’ 4.2.2. Adequacy. Patients also remarked ‘‘post partum I had to keep calling for pain meds.’’ 4.3. Newborn care. Newborn care was an important service that patients identified. It was divided into perceived quality of care, location, feedings, security, and maternal infant bonding. 4.3.1. Perceived quality of care. Patients noted ‘‘nursery was good; quick competent response to needs of my baby after delivery.’’ 4.3.2. Proximity. Patients commented about having the baby in the room with them after delivery: ‘‘like that we have the baby in the room’’ and ‘‘we didn’t like them taking the baby away.’’ 4.3.3. Timing of feedings. Patients also were concerned regarding the timing of feedings: ‘‘different opinions abut feeding the baby during the night.’’ 4.3.4. Security. Patients wanted to feel that their children were ‘‘safe.’’ 4.3.5. Maternal infant bonding. Having time to immediately bond with the baby was also important to women: ‘‘the baby came to me immediately after delivery; I had enough time holding her after delivery, they were very sensitive to this, I didn’t feel rushed.’’ 4.4. Breast-feeding. Breast-feeding was an important aspect of patient satisfaction and was subdivided into education, support, and attitude.
181 4.4.1. Education. Patients noted: ‘‘staff very helpful with breast-feeding; like to stay longer in the hospital to have more coaching on breast-feeding; all my questions handled extremely well.’’ 4.4.2. Support. Patients remarked: ‘‘need more breastfeeding support; everyone was right there, a nurse was with me at all times.’’ 4.4.3. Attitude: Patients also noted that many staff had strong opinions about breast-feeding: ‘‘too forceful with breast-feeding.’’ 4.5. Discharge preparation (beyond scope of this project). Interviews occurred before patients received discharge instructions. 5. Hospital attributes. Various aspects of the hospital were included as sources of patients’ satisfaction. 5.1. Administrative services. Administrative services evoked comments about perceived overall quality of care, efficiency, and family oriented focus. 5.1.1. Perceived overall quality of care. For example, ‘‘Overall the system works well; the whole labor and delivery staff was extraordinary.’’ 5.1.2. Efficiency. Patients remarked positively and negatively about efficiency of the hospital: ‘‘efficient; pretty easy, smooth’’ and ‘‘it took forever.’’ 5.1.3. Family oriented focus. Family friendly atmosphere was important to patients: ‘‘It was nice that they didn’t limit me to having just my husband, I had my niece and mother as well.’’ 5.2. Physical surroundings. Physical surroundings was subdivided into aesthetics, comfort for patient, comfort for partner, cleanliness, and parking. 5.2.1. Aesthetics. Rooms were described as ‘‘great rooms.’’ 5.2.2. Comfort for patient. Patients noted their comfort: ‘‘disliked the bed, very uncomfortable.’’ 5.2.3. Comfort for partner. Patients also noted their partner’s comfort: ‘‘like that the husband can stay; need better recliners for husbands.’’ 5.2.4. Cleanliness. Cleanliness was important to patients: ‘‘didn’t change the sheets enough; want cleaner room.’’ 5.2.5. Parking. Patients also noted parking: ‘‘When I came to the ER there was a problem with parking. should be smoother.’’ 5.3. Institutional food. Attributes of food were divided into variety and quality. 5.3.1. Variety. Patients remarked: ‘‘need more variety.’’ 5.3.2. Quality. Patients also commented: ‘‘food was great; food was terrible.’’ 6. Personal focus. Patients emphasized an inward focus about their delivery experience and this was divided into: overall experience of pain, positive affirmation of birthing process, feeling understood, having their preferences respected, privacy, choice, and other. 6.1. Overall experience of pain. Patients complained about childbirth-associated pain with general statements such as ‘‘The pain.can’t say much about this, nothing to do with the hospital itself that I disliked.’’
182 6.2. Positive affirmation of birthing process. Patients remarked that throughout the process they received positive affirmation from the staff and they were ‘‘enthusiastic,’’ ‘‘supportive,’’ and ‘‘reassuring.’’ 6.3. Feeling understood. Patients wanted to feel understood: ‘‘they were understanding.’’ 6.4. Preferences respected. Patients wanted their preferences respected: ‘‘receptive to my wishes, my wishes were honored.’’
Howell and Concato 6.5. Privacy. Patients commented on the lack of privacy: ‘‘no privacy.’’ 6.6. Choice. Patients wanted choice and options: ‘‘.got a choice for elective induction; make my own choice (for pain management during delivery).’’ 6.7. Other. The final category was other, which included support network for moms: ‘‘Mom’s support networkd nothing done to bring moms together.’’