Anesth Analg 2004;98:1099-1105
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000103265.48380.89
ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH
Patient Satisfaction with Preoperative Assessment in a Preoperative Assessment Testing Clinic
David L. Hepner, MD*,
Angela M. Bader, MD*,
Shelley Hurwitz, PhD, MS, MA
,
Michael Gustafson, MD, MBA
,
, and
Lawrence C. Tsen, MD* Section Editor
Departments of *Anesthesiology, Perioperative and Pain Medicine,
Medicine, and
Surgery, and the
Center for Clinical Excellence, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Address correspondence and reprint requests to Lawrence C. Tsen, MD, Department of Anesthesiology, Perioperative and Pain Med, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Address email to ltsen{at}zeus.bwh.harvard.edu
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Abstract
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Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 ± 0.67 and the average for the total instrument was 4.46 ± 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P < 0.0001). The satisfaction with the total duration of the clinic visit (3.71 ± 1.26) was significantly less (P < 0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively.
IMPLICATIONS: Patient satisfaction can serve as an important indicator of the quality of preoperative care delivered in Preoperative Assessment Testing Clinics (PATC). Information and communication, both from clinical and nonclinical service providers, remain the most important positive components, and the total duration of the clinic visit represents the most negative component, of patient satisfaction in a PATC.
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Introduction
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Providing high-quality, cost-effective preoperative evaluation of surgical patients is a key issue in perioperative patient management (1). Preoperative Assessment Testing Clinics (PATCs) have developed in an attempt to streamline the preoperative experience by coordinating surgical, anesthesia, nursing, and laboratory care. The use of such clinics for preoperative assessment has led to the development of practice guidelines and a decrease in the number and associated costs of consultations, lab tests, surgical cancellations, and length of admission (2–5). Although these improvements have benefited the hospital system, the patient experience with such clinics has not been adequately studied.
The use of patient satisfaction has been advocated as a unique clinical end-point and as an indicator of the quality of health care provided. Fung and Cohen (6) observed that the use of patient satisfaction as an outcome could be more insightful than the use of rare major outcomes such as death or common minor outcomes such as pain and nausea, which may be mired with significant methodological problems. Currently the limited data available on patients’ satisfaction with the overall surgical experience reflect the entire perioperative experience rather than a discrete evaluation of the preoperative assessment (6). These surveys, often conducted postoperatively, reflect a global perspective based on the many facets of care delivered, interactions with a number of health care and ancillary providers, and the outcome of the surgical procedure.
We chose to evaluate patient satisfaction during the preoperative period. This is when interactions with providers play a key role in reducing patient anxiety, assessing perioperative requirements, and communicating patient and provider information and concerns (7–8). More specifically, we wanted to evaluate patient satisfaction in the setting of a PATC. Previous internal survey development and testing work in our primary care, medical specialties, and surgical specialties practices helped highlight aspects of "office visits" of most importance to patients. These included the quality of explanation of medical conditions and treatment options, the extent to which questions could be asked and were answered, the support and comfort offered by staff, the courtesy and respect shown by staff, the amount of time spent with the provider, and the clarity of follow-up instructions. These aspects or dimensions of the experience are similar to those evaluated by nationally recognized inpatient satisfaction monitoring tools used at many medical centers throughout the United States, such as the Picker Institute survey (9–13). We hypothesized that by evaluating these and other general components immediately after interactions with anesthesia, nursing, and ancillary staff providers, we could more accurately define which elements contributed to patient satisfaction in the setting of a PATC. Furthermore, we hypothesized that both provider and nonprovider components would have a significant impact on patient satisfaction with their experience.
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Methods
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After approval by the hospital’s Committee for the Protection of Human Subjects, a one-page questionnaire was given to patients presenting to the PATC during three different time periods by one of the three unit secretaries (August, 2000; April, 2001; November, 2001) (Table 1). The questionnaire consisted of general questions (GENERAL) including the ease of locating the PATC, the type of surgery, an explanation of the PATC process by surgeon’s office as well as by the PATC receptionist, the courtesy and efficiency of the receptionist, and the length of time waiting to be seen. In addition, patients were asked about their visits with the anesthesia care provider (ANESTHESIA), nurse or nurse practitioner (NURSE), and laboratory technician (LAB), focusing on the courtesy and respect given, an explanation of the process and options, and the amount of time spent with a provider. All patients were interviewed and examined by a nurse or nurse practitioner, and an anesthesia resident, certified registered nurse anesthetist, or anesthesia attending. Finally, patients were queried with regard to their overall satisfaction (OVERALL) with the care and service received, the degree to which their questions were answered, and how prepared they felt for surgery. The last question on the questionnaire asked patients about their preference for a preoperative assessment done over the Internet.
In our PATC during the time period surveyed, nurse practitioners performed the history and physical (H&P) and nursing assessments on patients from neurosurgery, urology, vascular, cardiac, thoracic and general surgery. A physician assistant performed the H&P for orthopedic and plastic surgery patients, and a surgical resident performed the H&P for otolaryngology and gynecology patients. A nurse provided nursing education for patients who were not seen by a nurse practitioner. The anesthesia provider performed a separate H&P and assessment and determined whether additional testing or consultations were necessary. The laboratory technician acquired all necessary blood and urine testing, and performed an electrocardiogram.
The content and wording of many of the survey questions were imported from our institution’s internally developed and administered Primary Care Satisfaction Survey, initially developed in 1995 and subsequently modified during annual survey cycles to reflect patient and provider feedback. The PATC-specific questions were developed by the clinical leaders and providers to target both areas of perceived concern to patients and aspects of practice operations known to sometimes be problematic (e.g., expectation setting by the referring surgeon, wait times, and time spent with providers). The survey questions were reviewed with a small number of patients to check for clarity and comprehensibility before use. The patients used to test the questionnaire for clarity were not included in the analysis. Each question, except type of surgery and preoperative visit via the Internet, had five Likert scale options that ranged from excellent to poor (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor) (14). Patients were instructed to record free text comments regarding their PATC visit on the back of the questionnaire and to return the questionnaire at the end of their visit. The questionnaire was anonymous. The total amount of time spent in the PATC was derived from recording when the patient checked into and out of the PATC; the time spent with each provider was not collected. The time data were obtained only for the November 2001 time period with the implementation of a computerized time log system.
Means, standard deviations, and frequencies were used to describe the data. Subscales for each of the 5 sections of the survey were calculated using the means of the component question responses. Total satisfaction was calculated 2 ways: the mean of the 5 subscales (TOTAL 1) and the mean of the 18 individual questions (TOTAL 2). Factor analysis with varimax rotation confirmed the prespecified subscales. Independent sample Student’s t-tests were used to compare patient groups. Paired Student’s t-tests were used to compare scales and items within patient groups. Pearson correlations were used for the associations among the subscales within patient groups. Dependent correlations involving a common variable were compared with the Hotelling-Williams test (15). The trend across cycle was tested with the Jonckheere-Terpstra test. Cronbach’s Alpha (16) with (n = 177) and without (n = 855) listwise deletion was calculated to assess internal consistency overall, by service type, and by subscale.
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Results
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A total of 1200 questionnaires were distributed and 857 surveys were collected over 3 different months for a 71.4% collection rate. Of the patients receiving questionnaires, the proportion returning them was not significantly different by time period (73%, 72%, 68%; P = 0.36). There were 4243 patient visits during these 3 mo, and the collected questionnaires represented 20.2% of the visits. Data from 855 surveys were analyzed, as 2 of the surveys were blank. The questionnaire had 18 questions, and the mean number of answers was 16 (Table 2). Surveys were collected across all surgical specialties including otolaryngology, ophthalmology, gynecology, orthopedics, plastics, urology, neurosurgery, cardiac, thoracic, vascular, and general surgery.
The Cronbach Coefficient Alpha for the 18 items was 0.96, demonstrating that the instrument was reliable and consistent and that the set of items measured the patient satisfaction construct well. In addition, the calculations were performed by service type and by subscale with results ranging from 0.85 to 0.99.
Although the mean OVERALL satisfaction was 4.48 ± 0.67, the average satisfaction of all of the questions (TOTAL 2) was 4.46 ± 0.55 (Table 3). The average satisfaction for GENERAL was 4.19 ± 0.73 (Table 4). This was the least satisfaction of all the categories and was significantly less (P < 0.001) than the satisfaction with ANESTHESIA (4.58 ± 0.69, Table 4), NURSE (4.67 ± 0.59), LAB (4.63 ± 0.63), and OVERALL (4.48 ± 0.67). In contrast, the highest scores were given for ANESTHESIA, NURSE, and LAB.
Preoperative visit via the Internet, question 19, was not used to calculate the average number of questions answered nor to assess the internal consistency of the survey as this was a "yes, no, or not applicable" question. Although 62.32% of respondents would not prefer a preoperative assessment done over the Internet, 29.17% of respondents would prefer the use of the Internet. The remainder of the respondents, 8.51%, mentioned that the use of the Internet was not applicable to them.
There was a trend (mean = 4.72 ± 0.58 versus 4.64 ± 0.62, P = 0.07) towards greater patient satisfaction for NURSE when the nurse practitioner did the H&P and provided patient education compared with when the nurse did only the patient education and the surgeon did the H&P (Table 5). Table 6 presents the trends in patient satisfaction across the 16-mo time as reflected by the instrument subscales. ANESTHESIA was the only area that improved significantly across the time period (P = 0.007). The data show that the trends for the other subscales including OVERALL were flat.
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Table 5. History and Physical and Nursing Assessment by Nurse Practitioner Compared with Surgeon/Physician Assistant
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A subscale was defined that involved information and communication (INFO) with questions 1, 3, 4, 6, 8, 11, and 13. The correlation between INFO and OVERALL was r = 0.76 (P < 0.0001) (Table 7). The correlation between GENERAL and OVERALL was 0.66 (P < 0.0001), but this correlation was significantly lower (P < 0.0001) than the correlation between INFO and OVERALL. The correlation between OVERALL and ANESTHESIA was 0.65 (P < 0.0001), and this was not significantly different (P = 0.47) from the correlation between OVERALL and GENERAL (Table 7). Patients spent an average of 2 h 18 min in the PATC, and there was a significant correlation between the satisfaction with the length of time spent in the PATC (question 5) and OVERALL (r = 0.54, P < 0.0001). The responses to question 5 (3.71 ± 1.26) were significantly less (P < 0.0001) than those to question 16 (4.52 ± 0.74) and the OVERALL subscale (4.48 ± 0.74). Most of the free text comments mentioned the long period of time waiting in the PATC.
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Discussion
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Consumerism is playing an increasingly important role in health care decisions by patients (17–20). The reputation of a specific hospital or health care provider can be influenced by state, national, or payor rankings of relative quality performance for certain conditions and by patients’ satisfaction ratings of their experience (21–22). In fact, the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality are advocating for a national quality reporting program that includes development of a "national patient experience survey" currently under pilot in Arizona, Maryland, and New York.1 In addition, both the use of health care services and the outcomes of care delivery have been associated with patient satisfaction (23–24).
Patient satisfaction with perioperative care, however, remains largely undiscovered, with only preliminary investigations available (6–7). The results of these investigations are hampered by assessing satisfaction data at the end of the postoperative period, when patients’ judgements may be confounded by the outcome of their surgery, their interaction with a number of health care personnel, and other environmental factors. In addition, the majority of these investigations consist of mail-back questionnaires or postoperative telephone interviews often conducted several days or weeks after the perioperative experience, potentially making the responses less accurate (6). In terms of patient satisfaction with preoperative care, there is only one study that assessed satisfaction with prior anesthetics, but it did not assess satisfaction with the preoperative visit for the upcoming surgery per se (25).
To avoid the shortcomings mentioned above, our investigation consisted of a single anonymous, Likert scale multiitem questionnaire that the patient completed immediately before finishing their PATC visit. Multiitem questionnaires, with room to write in comments, were specifically chosen because of their ability to reveal lower degrees of satisfaction (6). Three different study periods were used to test for consistency. Our results indicate an overall very good or excellent satisfaction with the PATC experience in most patients during all three cycles. Satisfaction was highest for visits with clinical providers and correlated with an explanation of the process and the amount of time spent with a specific provider. Satisfaction was lowest with nonclinical aspects such as the surgeon’s office explanation of the PATC process, the receptionist’s explanation of what the PATC visit would involve, the ease of locating the PATC in the hospital, and the length of time waiting to be seen. Receptionists have often been viewed as "gatekeepers" to the doctor, nurse or surgery (26–28), and their attitudes and actions play a key role in patient satisfaction (26). Our findings emphasize the importance of nonclinician elements in improving patient satisfaction, and underscore the need for first contact staff members, such as receptionists, to be well informed and aware of the importance of their roles. This awareness can be gained by providing patient feedback and has been demonstrated to make beneficial changes in behavior (18).
For the clinician, the goals of preoperative assessment have multiple purposes: to assess the patient’s condition for anesthesia and surgery, to discuss and explain anesthetic and surgical options, to reduce anxiety, to discuss postoperative pain management options, to coordinate patient care among different members of the medical team, and to obtain informed consent (8). Patient goals are not dissimilar and meeting them has an impact on satisfaction; survey items associated with information and communication (INFO) were highly correlated with overall patient satisfaction (OVERALL). Our results support the findings of a postoperative survey in which outpatients ranked highest the components that dealt with information and communication, whereas the anesthesiologists overestimated the value of a smooth and efficient preoperative visit (7). This underscores the earlier reports that communication and information by a physician are strongly associated with patient trust and lead to increased satisfaction (29–30). Of interest, those patients evaluated by a nurse practitioner, versus those seen by a nurse and a surgical clinician (physician assistant or surgical resident), had higher satisfaction scores. In part, this may be the result of the nurse practitioner spending more continuous amount of time with each patient, as opposed to a separate visits with a nurse and a surgical clinician, enabling a better dialogue to ensue. It is also possible that a nurse practitioner is able to see things more similarly to patients (31), be more approachable or knowledgeable about particular aspects of care, or impart a better sense of comfort and confidence than surgical providers (32). Further studies will be needed to elucidate these answers.
The only category to undergo progressive improvement over the three survey periods was the satisfaction with the anesthesiologist. Although responses from the first survey were very good (average, 4.50), continued improvement was noted in the 2 cycles (4.62 and 4.67 respectively). In part, we believe these to be a product of a 2-week rotation for residents, initiated after the first survey, which highlighted issues such as professionalism, interpersonal skills, and the purposes of the preanesthetic visit. Our findings may also underscore the importance of staffing consistency in the PATC. In our PATC, the most dynamic staffing variable is the anesthesiologist, which involves the rotation of approximately 80 resident anesthesiologists and a large pool of attending anesthesiologists; after the first survey, we limited the staff anesthesiologists to a group of 15 with a strong interest in perioperative medicine. Similarly, the nursing and laboratory staff are limited in number and work exclusively in the PATC. This consistency in staffing may allow all practitioners to better understand and allay the concerns of patients regarding specific surgical and perisurgical events.
The least satisfaction was given for the overall time spent in the PATC, which in the last survey period was an average of 2 hours 18 minutes; unfortunately time data were not recorded during the other two survey periods, as the computer program was not yet in place. Length of time waiting to be seen in a doctor’s office or awaiting surgery correlates inversely with patient satisfaction (30,33–34).
A possible limitation in our study was the intentionally limited number of surveys distributed. The response rate for each survey cycle was more than 70% for each cycle, but these responses represented only 20% of the patients seen during those time periods in our PATC. Although we believe our study population to represent an adequate sample size, it is possible that our results could be nonrepresentative of the surgical population served by our institution. However, the surveys were distributed independently of age, sex, co-morbidities, and surgical procedures. In addition, the response rate was similar for each survey cycle and although our survey respondents were most likely undergoing gynecologic, orthopedic, and general surgeries, the proportions were consistent with the surgeries performed at our institution. Moreover, no significant differences in overall satisfaction were observed by type of surgery. As such, we would not anticipate that a larger response rate for a particular surgical population would bias the overall results. Another potential limitation is that different patients participated in each cycle, thereby detracting from a robust longitudinal comparison of satisfaction. However, this reflects the nature of surgical interventions, and the samples were statistically similar, with large numbers and preserved patient demographics from cycle to cycle. In addition, the nonanesthesia subscales did not improve, contradicting the potential criticism that patients enrolled later had an intrinsic tendency toward more satisfaction than patients enrolled earlier. Finally, our results could be criticized for when the questionnaires were distributed. The surveys were completed at the end of the PATC visit, before the patient leaving. Almost all questionnaire-based studies mail the survey to the patients’ homes, giving them a chance to reflect on their experiences and ensure increased comfort and confidentiality. In addition, this would allow patients to complete the surveys after the surgery and reflect on the information obtained during the PATC visit. However, surveys were completely anonymous, responses were batched and analyzed several days or weeks after their completion, and the patients were made aware that no attempts would be made to correlate their results to the individual. Furthermore, surveys completed after patients get home from the surgery reflect contributions not only from the PATC but also from the surgeon, surgeon’s office, education materials, operating room staff, and inpatient ward staff.
It is difficult to determine the extent to which our findings can be transferred to other institutions or settings, as the absence of practice standards allow a variety of practice patterns to exist. Nonetheless, we have demonstrated that a tool can be designed to assess PATC practices and components and identify areas for improvement. Of note, we are currently using our survey instrument at a community hospital partner to reveal areas of improvement and issues common or distinct to community versus academic PATC settings.
A number of strategies can be promulgated for PATCs based on our results. Providing patient feedback to the clinical and nonclinical services, including the surgical office staff and PATC receptionists, on the purpose and time commitment required for a PATC visit would be of value. As the duration of the PATC visit is an important source of patient complaints, attempts to streamline patient flow, provide patients with information on their progress, and eliminate redundancy in medical questioning could be of benefit. By recognizing and reacting to patient expectations, dissatisfaction with their care can be minimized, and improvements in the clinician-patient relationship can be realized (35). Finally, designing workshops and sessions on achieving customer service excellence and appointing staff interested in the PATC process would be expected to improve satisfaction. As a result of our study, we have initiated many of these strategies.
In summary, patient satisfaction represents an important clinical end-point that can affect future patient health care decisions. Recognizing that patient decisions have a significant and growing impact on the health care industry, new health care directions must include an analysis of patient satisfaction. The practitioner and functional aspects of the preoperative visit, specifically in the setting of PATC, have a significant impact on patient satisfaction. Information and communication, both from clinical and nonclinical service providers, remain the most important positive components, and the total amount of time spent represents the most negative component of patient satisfaction in a PATC.
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Acknowledgments
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We thank the Biostatistics Consulting Service, Center for Clinical Investigation, Brigham and Women’s Hospital for statistical analysis support.
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Footnotes
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1 http://www.hhs.gov/news/press/2002pres/20021212.html 
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Accepted for publication October 8, 2003.
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Abstract
Introduction
