Satisfaction Survey i A SURVEY OF PATIENT SATISFACTION IN THE AMBULATORY SURGERY ENVIRONMENT UTILIZING QUALITY INDICATORS By ‘Melinda M. Tabi A thesis submitted to the Faculty of D’Yowville College Division of Academic Affairs in partial fulfillment of the requirements for the degree of Master of Science in Health Services Administration Buffalo, NY April 9, 2008UMI Number: 1452575 Copyright 2007 by Tabbi, Melinda M. All rights reserved INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality ilustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction In the unlikely event that the author did not send a complete manuscrist and there are missing pages, these will be noted. Also, if unauthorized ‘copyright material had to be removed, a note will indicate the deletion UMI UMI Microform 1452575 Copyright 2008 by ProQuest LLC. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 E. Eisenhower Parkway PO Box 1346 Ann Arbor, Ml 48106-1346Satisfaction Survey ii Copyright © 2007 by Melinda M. Tabi. All rights reserved. No part of this thesis may be copied or reproduced in any form or by any means without written permission of Melinda M. Tabbi.Satisfaction Survey iff THESIS APPROVAL Thesis Committee Chairperson ‘Name: Muth Aan ce Discipline: Health Services Administration Committee Members Discipline:_Health Services Administration _ ‘Name: x LZ ; 7K Z Ze Discipline: Physical Theray Thesis Defended on April 9, 2008Satisfaction Survey iv Abstract ‘The specialized environment of Ambulatory Surgery Centers, which have been rapidly integrating into the health care system, requires a unique assessment of patient satisfaction. Many existing tools used to measure patient satisfaction have limitations translating into this demographic. Data was obtained by a local ambulatory surgery center using a pre-existing questionnaire based on quality indicators prevalent in research. The de-identified data was released to this researcher to be coded and analyzed to uncover demographic and satisfaction trends. Respondents ranked their agreement with twenty statements and shared their personal characteristics including age, zip code and marital status. Descriptive statistics were used to assess patient satisfaction overall, and as it relates to the quality indicators. Inferential statistics were run, in the form of multiple regression analysis to determine the influence, if any, demographic characteristics have on patient satisfaction.Satisfaction Survey v Acknowledgement I would like to thank my thesis director, Dr. Walter Iwanenko for his constant guidance and support throughout this research process. I would also like to thank my committee members Professor Elizabeth G.E, Miranda and Dr. Eric R. Miller, without whose assistance this research would not have been possible. To my family, who has been a source of strength and encouragement through this whole journey. Above all I must thank my most steadfast supporter, my husband, who put my needs ahead of all else throughout this process, providing me solid foundation of love.Satisfaction Survey vi Table of Contents List of Tables List of Figures List of Appendixes Chapter I. INTRODUCTION Statement of Purpose 1 Theoretical Framework : : : 2 Significance and Justification ...........- 10 Assumptions . 10 Research Questions . u Definition of Terms ul Variables 12 Limitations 4 Summary 15 I. REVIEW OF THE LITERATURE .. 16 Introduction .. 16 Quality Indicators... : 16 Identifying Quality Indicators . 16 ‘Nursing Care 17 Communication 2 Environment 2B Outcomes .. 26 Demographic Characteristics 29 Creating a Patient Satisfaction Survey 32 The Use of Patient Satisfaction Surveys 32 Alternative Instruments 35 ANA Nursing Report Cards 36 PSI-19 ... . 37 Press Ganey Survey 37 QHCQ 38 SF-36 39 Support for the Survey Method .. 41 Summary ....... 42MIL, Vv. References Appendixes ...... Satisfaction Survey PROCEDURES FOR COLLECTION AND TREATMENT OF DATA .. Introduction Setting Population and Sample Data Collection Methods ..... Human Rights Protection ..... Treatment of Data Summary ANALYSIS OF DATA .....-- Introduction . Description of the Sample Research Questions . Data Collection Tool Summary ..... RESULTS .... Summat Conclusions Relationship of the Results to the Conceptual Framework ... Relationship of the Results to the Literature Relationship of the Results to the Research Questions .. se Relationship of the Results to the Variables «......... Relationship of the Results to the Study Design and Data Collection Methods... Relationship of the Results to the Data Collection Tool .. Relationship of the Results to the Statistical and Data Analysis Methods .... Implications for Practice, Management or Education ..... Recommendations for Future Research .. vii B 43 B 44 44 45 45 45 47 47 47 33 64 64 66 66 68 68 69 2 B 16 7 1 1 80 82 86Table 10. i. Satisfaction Survey List of Tables Descriptive Statistics- Demographic Characteristies . Descriptive Statistics- Age and Income of Respondents ... Descriptive Statistics- Surgeon Performing Procedure (1 =216) Descriptive Statistics- Area of Surgeon Specialty (n=216)...... Overall Patient Satisfaction- Responses to all Questions . Patient Satisfaction by Quality Indicator .... Multiple Regression: Demographic Characteristics and Total Satisfaction Multiple Regression: Demographic Characteristics and Nursing Care... Multiple Regression: Demographic Characteristics and Communication ... Multiple Regression: Demographic Characteristics and Environment .. Multiple Regression: Demographic Characteristics and Outcomes . 70 viii 49 50 31 58 60 61 62 63Figure 1 Satisfaction Survey List of Figures General System Theory as Illustrated by Ludwig von Bertalanfly ... System Theory as Interpreted for Health Care Managers by Joan Gratto Liebler and Charles R. McConnell ... System Theory as Interpreted for the Purposes of this Retrospective Exploratory Study ixSatisfaction Survey List of Appendixes . Appendix A Institutional Review Board Full Approval Letter ... 86 B Questionnaire : 88 C Letter of Permission to Share Data ........-:+essse a1Satisfaction Survey 1 CHAPTER 1 INTRODUCTION Patient satisfaction surveys have long been used in many capacities and in many fields of study to observe how well expectations of health care consumers are being met. The health care industry is one of the most rapidly growing and changing in our society. For each facility, it becomes increasingly important to have communication with consumers of their product to make sure there is stability in the delivery of services. There are many existing tools that have been designed for different types of health care organizations (hospitals, physician practices etc.). These tools have been studied and presented in the body of literature that represents health care. One limitation of these tools is that they do not necessarily translate across facilities, meaning that a hospital survey would not be looking for the same information as a physician practice survey. Ambulatory surgery centers, as an emerging force in the healthcare industry, in particular lack a specialized tool to suit their needs. A tool aimed at just this task was developed by a Western New York area surgery center that agreed to allow the responses to be studied for the purposes of this thesis. Statement of Purpose ‘The purpose of this retrospective exploratory study is to describe what the level of patient satisfaction is in the participating ambulatory surgery center. InSatisfaction Survey 2 addition, this study will explore if specific demographic characteristics influence patient satisfaction. Theoretical Framework The way a facility operates is not by accident, it isin facta living organism, an open system, exchanging matter with its environment (Bertalanfiy, 1968). To understand this exchange is to understand general system theory as it is was presented by Ludwig von Bertalanffy (1968). The approach of general system theory is more of'a macro versus micro approach, Bertalanffy states that itis necessary to study not only parts and processes in isolation, but also to solve decisive problems found in the organization and order unifying them, resulting from dynamic interaction of parts, and making the behavior of parts different ‘when studied in isolation or within a whole. In essence, to know the parts and how they operate with respect to the whole gives one an understanding that when changes are made to the parts it has an affect on the organization as a whole. The key is to identify what parts need changing. Following is a diagram of how Bertalanfiy illustrated the concept of general system theory.Satisfaction Survey 3 Stimulus Message Message Response ——— Receptor Controt Effector a ‘Apparatus Feedback Figure 1 General system theory as illustrated by Ludwig von BertalanffySatisfaetion Survey 4 The adaptation of this mathematical theory into the healthcare environment was accomplished by the work of Joan Gratto Liebler and Charles R. McConnell in their book titled Management Principles for Health Professionals, fourth edition, The authors indicate that each school of ‘management tends to place the focus on one particular feature of the organization. Management in particular tends to be concerned mainly with the functions of the manager and technology. The systems approach takes a look at the organization as a whole. This includes the intemal components, external components, the people within the organization and the processes that make up the overall environment of the organization. This more flexible approach enables health care managers to visualize their organization and how the different parts work together. By knowing this, the manager is able to understand that the changes they make to one portion of the system will have an effect on the other components and thus the organization as a whole. By taking the perspective of the organization as a living organism, it makes it easier to then understand how the establishment interacts with its environment. In addition to crediting the foundational work of Bertalanffy, Liebler and McConnell also explore the contributions of Kenneth E. Boulding to systems theory. Boulding developed a hierarchy of systems which helped bridge the gap between the theoretical and empirical systems of knowledge (Liebler & McConnell, 2004). This hierarchy acknowledged that the basic framework of general systems theory was effective for all areas of science, includingSatisfaction Survey 5 management. Each discipline that interprets this theory will draw on its own subject matter. The primary focus of the person applying the theory is to develop it to meet the needs of their particular area of interest. The work of Boulding includes specific areas of application including cybernetics, data-processing systems, rhochrematics, network analysis and finally administrative systems. Each area has a specific flow of communication and information resulting in an open system that fits a particular role. Determining the role helps to understand how the interaction works and subsequently the effects of any changes made. The system as interpreted by Liebler and McConnell (2004) contains four basic components: inputs, throughputs, outputs and feedback. Inputs are elements of or around the system that must be accepted because they are imposed by outside forces. These can include constraints such as governmental regulation and economies, necessities such as bricks and mortar and raw materials, demands of the system such as deadlines, priorities and conflicts and finally goodwill or general support. Inputs for the healthcare environment include characteristics of clients, length of stay, payment status, legal and accrediting agency requirements, institutional licensure, licensure of health care practitioners, federal and state laws conceming employees and goals of the organization including patient care, Throughputs, also defined as processes, describe the process by which inputs become outputs, This can be analyzed by work sampling, methods improvement, staffing patterns and the physical layout of the facility. Managers have control on the throughputs by changing the process through such measures as policy andSatisfaction Survey 6 procedure development. Outputs are identified as the goods and services produced by a particular organization. These outputs can be frequent and predictable as in the case of patient care, which is a goal of many health care organizations. The outputs can also be infrequent, yet still predictable as in the case of a reaccredidation process or changes in federal programs that need to be implemented in the facility. These kinds of outputs can be planned for by the managers and thus can be effectively controlled. When an output is not predictable, it does not mean that managers cannot plan for it; in fact it is essential to the success of an organization that unpredictable outputs are dealt with prior to their occurrence. Examples of unpredictable outputs include number of walk-in patients, employee turnover, telephone calls, seasonal disasters and changes in the number and types of clients. The final component of this theory is feedback. Feedback is the process by which inputs and throughputs are adjusted to produce new outputs, Some methods include market research, forecasting, client surveys, periodic accreditation surveys and periodic testing. The adaptation of this theory by Liebler and McConnell would look something like this when adapted to the model outlined by Bertalanffy,Stimulus Message Satisfaction Survey Message —— Inputs — Throughputs Outputs Figure 2 Feedback 7 Response System theory as interpreted for health care managers by Joan Gratto Liebler and Charles R. McConnell.Satisfaction Survey 8 For the purposes of this study the inputs throughputs and outputs are based on both the body of literature on this topic and the specific needs of the facility. The inputs, for this research are in line with some of those outlined by Liebler and McConnell. They include specifically the regulations of The Accreditation Association for Ambulatory Health Care (AAAHC) which is the accrediting body of this organization. The throughputs include quality indicators such as nursing care, communication, the environment of the facility and outcomes. These areas have been identified through the research as having an impact on patient satisfaction, The outputs for the purposes of this study will be the level of satisfaction of the patients as indicated by the survey. The feedback loop reflects the recommendations for change that result from the patient responses. Once the organization decides if changes will be made and implemented that starts the cycle over again as the changes are measured for effectiveness and influence on satisfaction. The final illustrated version of the framework looks like this:Satisfaction Survey Message Message Tous Throushous Outpuis ‘Stimulus Gov't Regs Nursing Care Level of ———> | AasH Regs Communication Satisfaction as Economics Environment of | | Indicated by the — | demands of Facility Survey System Outcomes Figure 3 Feedback 9 Response System theory as interpreted for the purposes of this retrospective exploratory study.Satisfaction Survey 10 Significance and Justification There is a lot of valuable information to be gained through patient satisfaction surveys. Studies have shown that by increasing satisfaction you are increasing the loyalty of your client base. The more patient visits that a facility able to perform, the greater chance they have for achieving a profitable financial picture (Swan, Conway-Phillips & Griffin, 2006). A favorable experience is far more likely to result in repeat visits as well as references to new clients by those you currently serve (Grundman, 2007). Increased levels of patient satisfaction for a given visit have also been proven to be indicative of their compliance with post- operative instructions resulting in a better outcome for the patient (Swan et al., 2006). When setting goals for quality improvement within a facility the inputs of the patients and their reflections on their experience can be indicative of areas to specifically target (Larrabee, 1996). When assessing the equality of care provided within a facility differences in care that patients received can be identified (Dansky, Colbert & Irwin, 1996). By identifying all of this information from a patient satisfaction survey, a facility is empowered to take what they now know and improve the experience for the patients accordingly. Assumptions 1, The patients will answer the survey honestly and with no ulterior motives or influencing factors. 2. The overall experience of all patients who will return the survey is the same. This includes a check-in process, an explanation of the procedureSatisfaction Survey ll and consent review by the nurse, performance of a procedure by a physician and instructions for post-operative care explained and given to the patient There is value to the information regardless of the type of procedure that a patient may be having. Research Questions What is the overall level of satisfaction in patients utilizing ambulatory care centers? ‘What is the level of satisfaction in patients utilizing ambulatory care centers within each quality indicator? What is the relationship of area of physician specialty, physician, age, gender, socioeconomic status, marital status, repeat visit and education level on overall satisfaction in patients utilizing ambulatory care centers? What is the relationship of area of physician specialty, physician, age, gender, socioeconomic status, marital status, repeat visit and education level within each quality indicator in patients utilizing ambulatory care centers? Definition of Terms 1. Quality Improvement- Operationally defined as initiatives put in place by management in order to improve the care given to the patient as, well as the patients’ perception of their experience.Satisfaction Survey 12 2. Ambulatory Care Center- Theoretically defined as a formally organized and legally constituted entity that primarily provides surgical procedures to patients which shall be completed on the same day that a patient is discharged with no provision of overnight observation (Grundman, 2007). 3. Quality Indicator- Theoretically defined as evidence based links between performance and health improvement that can be documented and measured relating to a target population (Sawyer, Berkowitz, Haber, Larrabee, Marino, Martin, Mason, Mastal, Nilsson, Walbridge & Walker, 2002). 4. System- Theoretically defined as an assemblage or combination of things or parts forming a complex or unitary whole (Liebler & McConnell, 2004). 5. Systems Approach- Theoretically defined as the relationship and interdependence of the parts, moving beyond structure or function(e.g organization charts, departmentation) to emphasize the flow of information, the work, the inputs, and the outputs. Systems add horizontal relationships to the vertical relationships contained in traditional organizational theory (Liebler & McConnell, 2004). Variables The variables in this study are as follows: Independent Variables-Satisfaction Survey 13 1, Area of physician specialty (i.e. ophthalmology, plastics, orthopedics) ~ this categorical variable can be extrapolated based on physician data, 2. Physician ~ this categorical variable is noted on page one of the survey distributed by the participating facility 3. Age - this continuous variable is recorded on page two of the survey distributed by the participating facility. 4, Gender - this categorical variable is recorded on page two of the survey distributed by the participating facility. Socioeconomic status — this variable is based on the median income estimated from zip code, recorded on page two of the survey distributed by the participating facility. 6. Marital status - this categorical variable is noted on page two of the survey distributed by the participating facility. 7. Repeat visit - this categorical variable is noted on page two of the survey distributed by the participating facility. 8. Education level - this categorical variable is noted on page two of the survey distributed by the participating facility, Dependent Variables- 1. Overall Patient Satisfaction as measured by totaling all twenty questions on the page one of the survey tool developed and distributed by the participating facility.Satisfaction Survey 14 2. Nursing care patient satisfaction as reflected in responses to questions one through five on the page one of the survey tool developed and distributed by the participating facility. 3. Communication patient satisfaction as reflected in responses to questions six through ten on the front page of the survey tool developed and distributed by the participating facility. 4, Environment of the facility patient satisfaction as reflected in responses to questions eleven through fifteen on the front page of the survey tool developed and distributed by the participating facility. 5. Outcome patient satisfaction as reflected in responses to questions sixteen through twenty on the front page of the survey tool developed and distributed by the participating facility. Limitations There are a few limitations to the research conducted in this exploratory study, The first limitation is the fact that there is only one facility involved in the study. This means that the data collected might not be transferable to other facilities that may have a different process, client or surgical base. Another limitation is the fact that the method for collecting the data was done using a convenience sample, not a true random sample which is the preferred method for data collection, Finally the tool that is being used, while based on well-founded research has not been proven to have any level of reliability or validity within itself.Satisfaction Survey 1s Summary This chapter addressed the statement of purpose for this study which is to determine the level of patient satisfaction within the participating facility and see what demographics influence satisfaction. The theoretical framework based around the concept of system theory developed initially by Ludwig von Bertalanfly (von Bertalanffy, 1968), further by Kenneth E, Boulding and adapted for health care by Joan Gratto Liebler and Charles R. McConnell (Liebler & ‘McConnell, 2004). The modifications made by the researcher based on the target area of study were also presented. The significance and justification for this study was presented based on literature that relates satisfaction levels to factors such as, profitability and patient outcomes. The assumptions that the respondents will evaluate their experience honestly, that every patient will experience a similar process through the facility and that each response, regardless of type of procedure performed has value were explained. Questions relating the quality indicators and overall satisfaction independently and in conjunction with demographic characteristics were presented to guide the research. Definitions for the terms quality improvement, ambulatory care, quality indicator, system and system theory were provided for the purpose of clarification. Variables to be explored at and dealt with, both independent and dependent were listed. Limitations relating to the tool and data collection methods were uncovered throughout the course of this study and presented in this chapter.Satisfaction Survey 16 CHAPTER II REVIEW OF THE LITERATURE. Introduction Ambulatory Surgery Centers are one of the newer markets in healtheare. Despite being among the fastest growing sites for patient cate, they are among the least studied (Swan et al, 2006), This chapter explores the vast body of health care literature that has been published and is accessible for research study. The literature revealed a large quantity of information regarding the establishment of quality indicators and how to measure for them. Demographic characteristics ‘were also identified in various studies and publications for measurement. Studies using surveys, the reason for the selection of that specific type of tool and the methods for distribution are described. Altemate instruments that presented in the literature are explored in the last section. Quality Indicators Identifying Quality Indicators The setting of ambulatory surgery centers is unique when compared to other areas of health care in several respects. Patients are going to be at the facility for only a short time, never more than a day (Grundman, 2007). ‘Throughout their time at the facility the patients spend more time with nurses, while they are aware, than the physician. All pre-operative screening andSatisfaction Survey 17 explanations by the doctor of what he or she will do will have already taken place in the physicians’ office. The nurse will spend time with the patient both before and after their procedure and they are responsible for the largest part of communication and assurance the patient will experience. Thus it is not surprising that nursing care joins communication, environment and outcomes as major indicators for quality which are prevalent in the literature Nursing Care The role of the nurse has been described in this way: “I am the eyes and ears of all providers” and “I am the front and back door of the hospital” (Swan et al., 2006, p. 317) Measuring patient satisfaction with nursing care encompasses concepts that deal with technical, interpersonal and educational aspects of care (Anthony & Higgins, 2006), Included in the broad topic of nursing care is provider concem for patient comfort, including pain management. According to Yellen (2003), patient satisfaction with pain management is defined as the patient’s opinion of how well nursing staff members managed his or her pain. It is ‘most often measured on a pain scale, the commonly accepted method by many accrediting bodies. In a study conducted by Dewar, Craig, Muir and Cole in 2003 regarding the effectiveness of a nursing intervention in relieving pain following day surgery, an outcome of improved pain management resulted from pre-op educational intervention, post-op follow-up and telephone advice (Swan etal., 2006) Nurses also provide education for the patient on pain medication and nonpharmacological alternatives for pain relief (Griffin & Swan, 2006). PainSatisfaction Survey 18 ‘management and the comfort of the patient also relate to the approachability of the nurse. The patient must feel comfortable throughout their interaction with the nurse in order to verbalize discomfort and have their questions about managing pain addressed (Yellen et al., 2002). Early in the visit, addressing the issue of pain management, the importance of letting the nurse know when there is a change in pain levels is important to be able to effectively manage the pain (Langemo, Anderson & Volden, 2002). The management of pain and explanation of treatment options is also an important attribute of quality nursing care to a parent, on behalf of their child who is the patient (Oermann, Lambert & Templin, 2000). ‘Managing pain is one of the most influential factors in patient satisfaction Effectiveness of pain management is related to level of functioning and activities, of daily living (Sawyer et al., 2002). By isolating pain and its association to patient satisfaction, itis thought that improved patient outeomes can be obtained (Yellen, 2003), ‘There was also indication in the literature that time with the patient including respectful interactions, listening, helpfulness and satisfactory explanations of the procedure and post-procedure instructions was important to the patient (Anthony & Higgins, 2006). Strength of the therapeutic alliance is defined as the degree to which there is a positive relationship between the client and the clinicians (Sawyer et al., 2002). Communication and courtesy on behalf of the clinician help to strengthen the bond with the client (Gandhi, Francis-Cook, Louise-Puopolo, Burstin, Haas & Brennan, 2002). Demonstrating caring behaviorSatisfaction Survey 19 and being attentive to the needs of the patient also appear in the literature as important to the patient (Oermann et al., 2000; Oermann & Templin, 2000), Maintaining professionalism throughout the visit is a quality of the clinician that impacts patient satisfaction as well (Dansky et al., 1996). Thorough explanation of post-procedure instructions has been linked positively with the patient adhering to the recommendations (Grundman, 2007). Spending time with the patient increases their level of trust for the nurse in turn enabling them to feel comfortable asking questions and gaining a perspective of what the procedure and recovery will be like. Staffing cut backs and downsizing have been shown to have a negative impact on the time a nurse has to spend with a patient (Shindul- Rothschild, Long-Middleton & Berry, 1997). It is important that a patient does not feel rushed when dealing with the nurse, The rushed feeling will make the patient feel uneasy and decrease their level of trust with the provider and comfort with the facility in general (Oermann et al., 2000). In order to be an effective educator the nurse must have a level of skill and expertise in the area they are providing education in (Ocrmann & Templin, 2000). The level of competence and skills of the provider have proven to be important to the patient throughout the literature (Yellen et al., 2002). These indicators reflect, the technical aspects of care the nurse exhibits (Gandhi et al., 2002; Dansky et al., 1996), Staffing levels which allow the nursing staff more time with the patient has been shown to have a positive impact on clinician skill and accuracy (Shindul- Rothschild et al., 1997). The contact with the nurse is especially important in theSatisfaction Survey 20 ambulatory surgery setting as they are the main source of clinical contact the patient has during the time before and after their procedure. Having a good skill set enables the nurse to assess the learning needs of the patient and their family ‘members in order to plan and deliver accurate and easily understood instructions and evaluate the outcomes of the instruction (Oermann & Templin, 2000). Thus the instructions or instruction methods can be tweaked depending on the needs of the patient, identifying those needs is where the level of skill on the part of the ‘nurse comes into play. It has been shown through the research that including the educational accomplishments of the provider increases the patients’ perception of skill of the provider. For example instead of just stating their name the nurse can introduce him/herself as a nurse practitioner, RN or LPN. The patient can be put more at ease that they are being treated by a skilled provider when made aware of their credentials, (Reed, Blegen & Goode, 1998). Furthermore, nurses who are certified within their area of specialty were perceived by patients to be more technically skilled in the administration of care (Oermann et al., 2000). Continuous initiatives to refresh nurse knowledge and inerease skills have also been proven effective in increasing the perception of the patient that the clinician is skilled (Langemo et al., 2002). Since links can be made between nursing care and patient outcomes it is not surprising that this topic emerged as a quality indicator in the literature (Swan et al., 2006)Satisfaction Survey 21 Communication The second area quality indicator identified through the research was communication, Communication is one of the most important keys to bridging the gap between patient expectations and their experience (Oermann, 2000). Giving the patient the respect that their time is valuable and that their needs are the top priority of a facility has been shown to be a great indicator of their satisfaction with the facility, One area of communication patients were concerned with was wait times and expectations of communication of a reasonable time table for their visit (Gandhi et al., 2002; Grundman, 2007; Dansky et al, 1996), There is a wealth of research in all aspects of health care that shows that wait times have a great effect on patient satisfaction. Shorter wait times have been associated with the perception that the staff'is kinder and more compassionate, as well as greater satisfaction with their medical care (Eilers, 2004), Essentially it sets the tone for their overall experience. Ifit is not possible to eliminate long wait times, then ‘communication becomes an important factor. Patients need to feel that they are waiting with a purpose; otherwise they are likely to blame a specific person or area and develop distaste for a facility. One of the more common patient perceptions when they are forced to wait is that they have been skipped ot forgotten, especially in a facility like an ambulatory surgery center where many doctors in many different areas of specialty can be practi 1g concurrently. Ifa ‘wait time cannot be shortened, it can be managed by creating the perception of a shorter wait. A comfortable waiting area with distractions like television,Satisfaction Survey 22 magazines and activities for children can aid in the change of perception. If they are distracted, patients will feel that they have been waiting for a shorter amount of time, Arranging chairs into clusters, using soothing colors, natural lighting and table lamps create a relaxing environment putting the patient at ease (Eilers, 2004). Accessibility of contact with providers and help during office hours was another area of importance to the patient that was uncovered through the research (Gandhi et al., 2002; Oermann et al., 2000; Oermann & Templin, 2000; Grundman, 2007). This area takes the value of the patient's time into consideration as well. The ability of the patient to get the answers they are looking for when they call a facility is a sign of the overall effectiveness of the facility in the eyes of the patient. The availability of having a nurse to call has been shown to be of great importance to a patient (Oermann et al., 2000). The nurse has the ability to answer questions relating to instructions for post-operative care and may be able to tell a patient if'a side effect they are experiencing is normal or not, At the very least the nurse will be able to tell the patient to contact, their provider for additional questions. Patients are also concerned with the ease of making an appointment with their provider or confirming a time of an existing appointment (Gandhi et al., 2002). The ability to talk to a person who can help a patient with a question or concern and the ease with which they are put into contact with that person is indicative of the organization and structure of theSatisfaction Survey 23 facility as a whole. If the patient has a positive experience it will be reflected in their overall satisfaction with the facility. Finally receiving the proper treatment or procedure was an area that was indicative of satisfaction (Oermann et al., 2000). This aspect of quality can be manifested as a large scale error like the procedure being performed on the wrong, side of the body, or a small scale error like an inaccuracy on the consent form that can be easily corrected. Changes in continuity of care can be a result of time allowed to provide aspects of care and authority to make decisions on behalf of the attending nurse, Allowing the nurse more time to provide care was positively associated with the ability to uphold professional standards (Shindul-Rothschild et al., 1997), Environment The environment of the facility is presented in the literature as an indicator of quality that affects the patient experience. The patient wants to feel that they are safe, surrounded by caring people and in a facility that is properly staffed and ‘managed. The first area that the patient will judge is the physical environment of the facility. One specific area that can influence patient satisfaction instantly is the cleanliness of the facility (Grundman, 2007). This is especially important in the case of ambulatory surgery centers where a level of cleanliness must be ‘maintained. Safety of the patient within a healthcare facility also impacts patient satisfaction, Making improvements within the facility to increase safety has resulted in increased overall patient satisfaction (Amin & Owen., 2006). TheSatisfaction Survey 24 perception of privacy is also important to the patient. The issue of privacy in healthcare has permeated all levels of legislation and has resulted in the enacting of legislation. One example of such legislation is the health insurance portability and accountability act (HIPAA). This regulation delineates the standards for privacy of the patient interaction with staff as well as privacy of medical records maintenance. Privacy not only impacts patient satisfaction, but the facility as a Whole in the form of repercussions such as fines when the law is violated. Soeial factors also have an impact on the overall experience of a patient, This includes being treated with friendliness and respect by the facility staff’ outside of their nurse contact (Grundman, 2007; Dansky et al., 1996). The respect and friendliness of the staff from the reception to the requests for medical records and even the administration can impact the patient's perception of a facility Friendliness can put a patient at ease and also give them the perception that this is, a good organization to work for if the staff seems content. A happy staff creates a better feeling for the patient (Dansky et al., 1996). Patient perception that the facility is properly staffed also places them at ‘ease and adds to the satisfaction of their experience. A facility may be fully staffed, but ifthe staff is unorganized, flustered, frustrated or rushing the perception by the patient may still be that there are not enough people working. ‘The patient wants to feel like they are getting the attention of a qualified and professional staff. They want to feel that they can ask questions of the staff, and the staff member has the appropriate amount of time to answer the patientSatisfaction Survey 25 questions completely. Sometimes a facility may not be properly staffed. In fact in a second look at the results of a 1996 Patient Care Survey published by the American Journal of Nursing researchers found that a reduction in registered nurses and registered nursing executives without replacement were two structural factors that most accurately predicated how a facility would be rated regarding the provision of care by patients. The facilities with higher numbers of registered nurses and executives were shown to be rated higher in level of care. In some cases the registered nurse staff is being replaced by unlicensed personnel and this study shows that the change is not going unnoticed by the patient and their perception of care (Shindul-Rothschild et al., 1997). Levels of staffing have also been positively associated with outcomes of the patients. There is a relationship between the ratio of total nursing staff and the quality of care. The level of quality in this case was measured by nursing related deficiencies. Fewer registered nurse and nursing assistants’ staff is associated with an increase in total deficiencies and quality of care deficiencies (Bostick, Riggs & Rantz, 2003). This indicates that ‘maintaining a proper level of staff will provide better outcomes which will provide better results relating to patient satisfaction One final area that was identified in the literature as having an effect on patient satisfaction with the environment was the teamwork of staff (Anthony & Higgins, 2006), The perception of the patient is that they will receive better care from a “team” than from an individual. A portion of the strength of therapeutic alliance as presented by Sawyer et al., (2002), coordination of processes amongstSatisfaction Survey 26 staff relates with the continuity of care that the patient perceives. The expectation of the patient is that if they told one person about a problem or concem that the message would find its way to all of the areas that a patient would experience. Having a system in place for constant communication between providers of care to the patient has been effective in increasing patient satisfaction and quality of care (Amin & Owen, 2006). The increased communication between care providers, across different roles creates an interdisciplinary team to function with the goal of acting on what is best for the patient (Amin & Owen, 2006). The influence of environmental factors on so many different levels confirms that patients are influenced greatly by what is around them. Creating an organized and professional environment does not only benefit the patients’ satisfaction, but the facility as a whole as well. Outcomes Another quality indicator present in the literature was patient outcomes. Outcomes following a procedure have been studied to have an influence on overall patient satisfaction with their experience within a clinical setting. In many acute care settings there are adverse outcomes such as pressure ulcers, nosocomial infections and other complications from a procedure (Langemo et al., 2002 ; Sawyer at al., 2002). One outcome that is of concem to patients having an outpatient procedure is returning to normal daily activities. Returning to normal daily activities is a measure of therapeutic effectiveness of the administration of care relating to level of functioning (Sawyer et al, 2002). It is also beneficial toSatisfaction Survey 27 measure if the return to daily activity varied from what the patient anticipated (Grundman, 2007). This measurement allows for the assessment of differentiation between expectations of the patient and actual results (Dansky et al,, 1996), The ability of a patient to recover as planned and resume normal activities has been shown to be correlated with their satisfaction, and also with their willingness to return to a facility for another procedure or recommend a facility to a friend (Dansky et a., 1996). Adherence to care recommendations is another indicator that is correlated with patient satisfaction relating to outcomes (Swan et al., 2006). The adherence to care recommendations as an outcome of the care administered by the facility incteases client self-efficiency, self care and quality of life following surgery. The higher level of satisfaction of the patient throughout their experience led them to follow the post-operative instructions more carefully resulting in a better outcome (Swan et al,, 2006). The patient perception that the instructions were easy to follow and explained well, along with the availability of having someone to verify the information with if they are confused will all lead to better compliance. If patients are finding the directions difficult or if the patient has a question following surgery, itis has been indicated in the literature that being able to call a nurse for clarification is a measure of quality of care (Langemo et al., 2002) One area that is negatively correlated with patient satisfaction is the increase in severity of pre-surgical symptoms or adverse effects following the procedure (Sawyer et al., 2002; Shindul-Rothschild et al., 1997). A change inSatisfaction Survey 28 symptom severity can be defined as the degree to which the client’s experience of the subjective evidence of their disease or illness varies (Sawyer et al., 2002). Patients should be educated about what they might experience after surgery along with their post-operative instructions. The nurses should also educate the patient on how to manage any changes in their symptoms effectively. There is always pain and healing after a surgical procedure, however when a patient is prepared to deal with the reaction it will not negatively affect their satisfaction with their experience within a facility. A procedure that results in a negative outcome or does not correct a problem as a patient had hoped it will be reflected in their satisfaction with a facility. In the case that there is an occurrence of more cases than expected where there is a sharp increase in pain or other complications outside of what is normal a patient satisfaction survey that indicates what areas may need to be adjusted to attain more positive outcomes. A patient or family member complaint is an outcome that is correlated with satisfaction through the research. (Shindul-Rothschild et al., 1997). A complaint is a verbal or written indication to the staff of a facility that there was an expectation not met by the patient in a particular area. Complaints, among other outcome measures of quality are frequent in the literature, however there has been a measurement problem relating to their occurrence. There has been inconsistent reporting of adverse occurrences making the collection of data problematic (Bostick et al., 2003). Using a tool to measure when a complaint is made throughout the process of a patient visit enables the collection of aggregateSatisfaction Survey 29 data that can be analyzed statistically and taken into account for the satisfaction rate (Bostick et al., 2003). Demographic Characteristics Many demographic characteristics of a population can be identified that can provide useful comparison data for later statistical analysis such as regression analysis. Two common independent variables that present in the literature are age and gender. These two variables have been used in many studies to determine the effect of disparities in the population on the perception of care. Much research has been done with the goal of identifying social and physical differences between the sexes and among different age groups. Some of the researched differences between the sexes are relating to diseases such as rates of depression, which are higher in women than men (Bebbington, Dunn, Jenkins, Lewis, Brugha, Farrell, & Meltzer, 2003). Women have also been found to be more likely to report physical and emotional distress, pain included when compared to men (McHomney & Fleishman, 2006). These differences, when evident to a degree of statistical significance provide valuable data for comparison. Differences in age groups exist as well; across numerous contexts older people have been shown to be more likely to refuse assistance when needed. This response is an attempt to reduce cognitive dissonance that results from the need for older people to be dependent on others. (McHomey & Fleishman, 2006). The positive association between age and desirability results in older people giving more positive reports on themselves, and their health than younger people. This phenomenon is referred to as theSatisfaction Survey 30 “positive response bias” and its presence affects the legitimacy of responses to questions (McHorey & Fleishman, 2006). In addition to identifying possible differences, the demographic data can identify what variables can be correlated with levels of satisfaction. If a specific gender or age group is identified as being particularly low relating to patient satisfaction the facility may want to pay particular attention to that demographic ‘group when determining the quality improvement initiatives (Reed et al., 1998; Oermann, 1999; Oermann & Templin, 2000; Langemo et al., 2002; Sawyer et al., 2002; Yellen, 2003). Another demographic characteristic that identified in the literature is socioeconomic status, Both survey researchers and sociologists have observed that persons of a lower socioeconomic status tend to be more concerned with displaying socially desirable behavior (McHomey & Fleishman, 2006). This demographic category has been used to compare respondents with others similar to their status and contrasted with those who are of a different status. This data can be used to determine if there is a correlation between this socioeconomic status and patient satisfaction (Sawyer et al., 2002). Education level has also been recognized in many studies as having a potential correlation with satisfaction, The education level can be broken down into variables for the respondent such as “less than high school” up to “masters level and beyond” These factors are coded and statistically analyzed to determine if they are correlated with the levels of satisfaction of the patients. If there is aSatisfaction Survey 31 correlation found the facility can utilize that information in their determination and implementation of quality improvement initiatives (Oermann, 1999; Oermann & Templin, 2000). In one study conducted by Oermann, Lambert and Templin (2000), education level was further broken down and associated with race as a demographic characteristic. By studying populations within other demographic populations the results can be even more specific The following two independent variables reflect the possible impact of level of comfort and the patient experience as it reflects on patient satisfaction. In the literature base marital status has been shown to have a positive correlation with the feeling of personal satisfaction and happiness. Married people have also been viewed by society in a more favorable light than single and divorced people (Stacy & Richman, 1997), There have also been positive correlations between social support systems like a spouse and a reduced mortality risk and a better health state (Coventry, Gillespie, Heath & Martin, 2004). This level of personal satisfaction can translate in to an increased level of comfort during an ‘uncomfortable situation (Oermann, 1999; Oermann & Templin, 2000; Oermann et al., 2000). In much the same way that accompaniment and personal happiness increase satisfaction, it is supported throughout the research that the level of comfort with an individual's surroundings can also put an individual at ease in an uncomfortable situation (Reed et al., 1998). The ability to assess this variable in correlation with the levels of satisfaction can assist in the identification of areas for improvement on behalf of a facility (Yellen, 2003).Satisfaction Survey 32 Creating a Patient Satisfaction Survey The Use of Patient Satisfaction Surveys In healthcare facilities it is vitally important that there is measurement of the perception of care that is received within a facility. One commonly used method of assessment is in the form of a patient satisfaction survey. Patient satisfaction has been strongly associated with patient retention. The loyalty of patients increases along with their level of satisfaction (Swan, Conway-Phillips & Griffin, 2006). If a patient has a good experience it is more likely that the individual will pass information about the facility on to their friends and family (Grundman, 2007). It has also been indicated in the literature that the more patients that come through a facility the higher your revenues and overall financial success (Swan et al., 2006). Incteased levels of patient satisfaction also have an influence on certain outcomes of care, Patients have been shown to be more likely to adhere to their post-operative care instructions when they have had a more highly satisfying experience (Swan et al., 2006). Collaboration with patients is the method used by patient satisfaction surveys to determine what interventions could be taken when setting goals for quality improvement (Larrabee, 1996). Differences in satisfaction may be a reflection of actual differences in care received by patients as well as differences in their individual expectations of care (Dansky, Colbert & Irwin, 1996). Furthermore, an assessment tool can identify areas within a facility that could be targeted with incentives to increase performance (Yellen, Davis & Ricard, 2002).Satisfaction Survey 33 ‘The process of developing a patient satisfaction measurement tool designed to meet the needs of a specialized environment and implementing it was the task taken on by researchers Kathryn H. Dansky, Calvin J. Colbert and Patricia Irwin in conjunetion with Pennsylvania State University. In January of 1995 the researchers examined the steps involved in designing a system to ‘measure patient satisfaction with the university's health care services. The researchers determined through the literature that many prevalent models for patient satisfaction theory are based on the expectations that patients have of the care they will receive. This model, known as expectancy theory explores the gaps between expectations and performance which create psychological tension for an individual. This tension will either represent itself positively or negatively relating to an individual's overall experience. There are areas in addition to quality of care associated with a patient’s experience that influence their perceptions as well. The literature explored for this study resulted in wait time; costs and friendliness of staff emerging as additional influences. The researchers determined that additional factors consisting of technical and interpersonal care, outcomes and. structural attributes of the setting would also be measured. When measuring patient satisfaction the researchers determined that quantitative measures would be their choice as a representation of data than qualitative measures because they are straightforward interpret. Satisfaction surveys are more subjective in nature. While not necessarily correlated with objective reality the results can mirror actual differences in care received withinSatisfaction Survey 34 the facility as well as the gaps in the individuals’ expectations versus what they experienced. This subjectivity can be a strength in the case of patient satisfaction, as the researcher is primarily concemed with identifying the perception and the differences in the expectations of care from the patient. ‘The researchers in this study developed and piloted their own instrument. Likert type, mixed and expectational scales were used to generate satisfaction data, The design and content were adopted from a compilation of similar surveys implemented elsewhere. The tool was pilot tested before being implemented in two focus group sessions. The pilot respondents rated the questions for appropriateness, length and number of the questions. The questions were adjusted after each session based on the reactions and suggestions of the participants. The final survey tool contained seven demographic questions relating to gender, age, student status, ethnicity, nationality and physical or learning disabilities. These are reflective of the research conducted in the area of study, in this case college students, and the factors which may provide comparable and significant results in determining patient satisfaction. The satisfaction items were organized into thirteen categories encompassing all areas of the facility experience. A total of 924 patients were given the survey with 314 valid responses, for a total response rate of 33.4%. The respondents were selected as a convenience sample of individuals who pursued care at the facility. The surveys were distributed upon registration and were collected at the checkout desk as patients were leaving the facilitySatisfaction Survey 35 Analysis of the data, including means, frequencies and standard deviations aided in the determination of the central tendency of the data. Additionally, cross- tabulations were utilized to identify relationships between various aspects of service and future patient behavior. To test the reliability of the data, Combach’s alpha t-tests were performed to identify statistically significant differences in the demographic groups and their responses. ‘The results found that the tool was reliable in a moderate to high degree in all areas but physical therapy. In terms of the validity of the tool, a larger number of focus groups in the piloting stage of development would have helped, however the researchers found that they had no reason not to consider the tool valid. The researchers concluded that to result in a better response rate, a recommendation is, to reduce the length of the survey. Additionally the way that the satisfaction questions were categorized leaves areas for non-response. Many of the categories ‘were tailored to the experience in a certain area like x-rays, pharmacy and physical therapy, That leaves those entire areas not applicable for those individuals who did not seek those services out during their visit. One last recommendation is not to hand out the surveys before the care is given, as this creates a heightened awareness of expectations. The researchers determined that handing the surveys out at the conclusion of the visit would avoid this bias. Alternative Instruments There are many examples in the literature of various types of surveys used and methods for creating one that is appropriate for use in a specific facility basedSatisfaction Survey 36 on their areas of interest. Many tools are valid, reliable and create useful data for a facility. Examples of tools used in previous studies include American Nurses Association (ANA) nursing report cards (Griffin & Swan, 2006; Bostick, Riggs & Rantz, 2003), Patient Satisfaction Instrument (PSI) 19, Press Ganey ambulatory surgery survey (Yellen, 2003), Quality Health Care Questionnaire (QHCQ), SF- 36 Health Survey (Oermann, Lambert & Templin, 2000). ANA Nursing Report Cards In 1994 the American Nurses Association launched a tool called the ‘Nursing Report Card to aid in the collection of consistent aggregate data relating to the performance of nurses. The specific focus of the report card was to draw correlations between nursing care and patient outcomes. The first implementation of this tool was targeted for the acute care environment. The questions focus on ten areas that have been developed through the National Database of Nursing Quality Indicators as prevalent for the acute care setting (Bostick et al., 2003) The ANA also tracks quality indicators for many other areas including patient safety and community based care (Griffin & Swan, 2006). This tool is a well researched and proven effective tool for obtaining nursing data, It provides useful quality indicators for the uses of this exploratory study relating to non-acute care like ambulatory surgery. What this tool is lacking is an encompassing viewpoint for an entire facility.Satisfaction Survey 37 PSII9 In a 2003 study conducted by the Texas Healthcare Information Commission a version of the Patient Satisfaction Instrument or PSI was used on an ambulatory surgery unit to determine patient satisfaction. This tool was comprised of fifteen questions grouped according to three different subscales. The first subscale is the technical-professional behavior of the nurse (alpha 0.83), the second subscale is interpersonal-educational items that deal with the social aspects of nursing (alpha 0.83) and finally the interpersonal-trusting relationship dimension (alpha 0.82), The reported total alpha reliability of this tool is 0.91, far above the 0.70 required for its consideration as an acceptable and reliable instrument, On this tool the respondents are asked to indicate their agreement or disagreement with a particular statement (e.g. “the nurse was skillful with procedures”). The responses followed a four-point likert-type scale ranging from “pot at all” to “very much so”. This tool is written at a sixth grade reading level and is available in both an English and a Spanish version. The same study also used the Press Ganey Ambulatory Surgery survey for half of their population. Press Ganey Survey The Press Ganey Ambulatory Surgery Survey has a fifteen year history of use in over 636 hospitals, The survey contains 32 items in accordance with five subscales, The subscales are: Patient satisfaction with registration, events before surgery, events after surgery, procedures and finally overall impressions. The respondents were asked for their response to a particular statement (e.g. “ rate theSatisfaction Survey 38 comfort of your room or resting area”). The responses were measured on a five- point likert-type scale with responses ranging from “very poor” to “very good”. ‘The alpha reliability for this tool is reported to be 0.97 with internal reliability coefficients of at least 0.86 for each subscale. The results of this study comparing these two tools found them both to be reliable and valid, and interestingly a Mann-Whitney test showed that the scores on the two tests were not significantly different, making them comparable tools. Fout variables relating to patient satisfaction were found to be the most indicative following the assessment of both tools. The first two represent quality indicators; they are communication with the nurse and satisfaction with pain management. The other two variables are demographic; they found that age and ethnicity were also significantly correlated with patient satisfaction. These tools are both examples of what could be used in an ambulatory care setting, Independently, however they both leave something to be desired. The PSI is only 15 items and itis entirely nurse oriented. The Press Ganey tool was ‘much longer, and more encompassing of a total experience, however at 32 questions it may be too long to get an appropriate response rate. The Press Ganey tool also addressed many areas within a facility such as EKG’s, labs and x-rays which may be too specific for many facilities. QHCQ The Quality Health Care Questionnaire (QHCQ) is a ranking tool used to ‘obtain information from the consumer about what indicators of quality are mostSatisfaction Survey 39 important to them. The QHCQ is made up of twenty seven items relating to health care and nursing quality. The indicators are ranked using a five-point likert-type scale with responses ranging from one (not at all important) to five (very important) The twenty seven items can be broken down through factor analysis into six factors which can act as sub-groups. The emerging factors are medical care, teaching by the nurse, provider competence, choice of provider, nurse- patient interaction and convenience of appointments, The QHCQ also collects demographic and background information (Oermann et al., 2000) ‘The format of this tool is good, it is valid and reliable. It has been piloted and proven to be very useful in obtaining information about what is important to a patient. The down side is that the tool is aimed toward the parent-child relationship and what is important to the parent in reference to their dependent child. The scope, however is limited to that unique population. SF:36 The SF-36 is a 36 item instrument for measuring health status in eight, general areas. The areas of measurement include physical functioning, role limitations because of physical-health problems, bodily pain, general health, vitality (energy or fatigue), social functioning, role limitations because of emotional problems, mental health. This tool is used in assessing differences in interpretation of quality of care for people with chronic conditions. Research has shown that people with chronic conditions may have a different definition of quality of care and that must be taken into account in order to have valid dataSatisfaction Survey 40 (Oermann & Templin, 2000). This tool is useful in identifying what questions to ask on a survey to ensure that all variables are covered. If not addressed health status could be an extraneous variable that would have an influence on the data, By measuring its presence it can he controlled for in the results. The population of patients having ambulatory surgery is unique, with the need for a specialized tool. There is a large body of research where different tools have produced different outcomes. By taking the recommendations from other studies into consideration there is the opportunity for a facility to create a specialized tool targeted for their population, and furthermore any facility that fits similar characteristics. There is support for the use of a likert scale for measuring patient responses (Langemo, Anderson & Volden, 2002; Oermann et al., 2000). They are generally comparable and provide reliable satisfaction data (Dansky et, al., 1996). There is also support for the inclusion of a question that directly asks the patient if they would recommend the facility to a friend or if they themselves ‘would retum. This type of question has been linked strongly to overall patient satisfaction with a particular facility (Dansky et al., 1996). There is support for keeping the length of surveys manageable, preferably limited to a single page (Wall, Engelberg, Downey, Heyland & Curtis, 2007). A tool developed by a facility should also be easy to fill out (Wall et al., 2007). The use of a theoretical framework such as concept mapping that enables generation of items which are indicators of quality, structuring those concepts by enabling them to be measured and interpreted as they relate to patient outcomes can assist with the developmentSatisfaction Survey 4 adjusted to meet the changing results from a of a tool which consistently population (Anthony & Higgins, 2006). Support for the Survey Method Surveys, when shown to be reliable and valid can fulfill many of the measurement needs of an organization, Surveys can provide valuable data that can be used for internal management within the organization. Quality improvement initiatives put into place by the staff of a facility are important efforts towards improving the overall patient experience and thus retaining a profitable patient base (Grundman, 2007). Survey results can be used as a base for compensation and incentives among all levels of an organization. Through the total ambulatory surgery experience patients are in contact with office staff, nurses, doctors and they can even reflect on such areas as maintenance and cleaning by expressing their opinion on their environmental surroundings (Gold & Woolridge, 1995). Surveys can also be used for external purposes. High levels of patient satisfaction can be used for marketing and recruitment of consumers, staff and even participating providers. Externally survey results, if reliable and valid can also be used as a benchmarking tool, enabling facilities to be ranked and know where they stand against one another. The desire to be at the top of the list can inspire organizations to make the necessary changes to improve patient satisfaction. Having a good reputation for satisfaction also enables an organization to work within the local environment and be proud to participate and sponsor community vents, thus furthering the reach of their marketing andSatisfaction Survey 42 recruitment (Grundman, 2007). In the same way the organizations are also accountable to the community if they are not meeting patient needs or if they are not providing equitable care within their facility. Having the survey data gives them the power to take that knowledge and make the necessary improvements to regain good standing within the community (Gold & Woolridge, 1995) Summary A comprehensive review of the literature for quality indicators for patient satisfaction resulted in the selection of four prevalent categories. Those categories consist of nursing care, communication, environment and outcomes. The research. also revealed many demographic characteristics which can be measured for. The demographics explored were age, gender, socioeconomic status, education level, ‘marital status and repeat visit, The process of creating a patient satisfaction survey as indicated by the literature was explored. The following section examined various measurement tools that were presented in the research. This was followed by a review of the literature which supports the survey method for the collection, of data.Satisfaction Survey 43 CHAPTER III PROCEDURES FOR COLLECTION AND TREATMENT OF DATA. Introduction This section describes the methods used to identify patient satisfaction Jevels within an ambulatory surgery center. The researcher will use existing data collected by the facility to analyze the satisfaction levels with regards to specific quality indicators as well as an overall measure. Based upon the data, areas for improvement will be identified. Setting ‘The questionnaires were handed out to the patients of a free standing ambulatory surgery center located in westem New York. The facility is a multi- specialty surgery center designed to perform same-day surgery procedures. Both state & federal licensing standards for quality care & safety are met within the center. The facility is licensed by New York State Department of Health, Medicare certified as well as accredited by Accreditation Association for Ambulatory Health Care. The number of patients seen varies around 200-300 per week. There are several specialties that are treated including ophthalmology, orthopedics, podiatry, otolaryngology, cosmetic surgery and pain management.Satisfaction Survey 44 Population and Sample ‘A convenience sample was collected by the surgery center from an accessible population of patients that visited the facility throughout the period of July 16-20, 2007 and August 13-17, 2007. The sample data resulted from 216 surveys that were returned. The survey had a total response rate of 60%. Data Collection Methods The tool that was distributed by the surgery center is a self-designed tool developed based on the research and targeted specifically for ambulatory surgery centers. The questionnaire had been pilot tested prior to distribution. Some medical terminology was rephrased and clarified as a result to make the questions more comprehensible to persons without a medical background. The questionnaire contained questions that have assorted collection methods for the distinctive variables addressed. There was the use of a 5-piont likert scale when obtaining information regarding satisfaction. The tool also asked the patient to fill in their physician and date of surgery along with several demographic questions. ‘The nurses within the facility distributed the surveys to the patients with their post-operative instructions at the conclusion of their visit. The patients were asked by the nurse to fill them out and return them at their convenience for the use of the facility in a self-addressed stamped envelope. The questions in the survey were directed toward the patient. Upon the return of the responses to the facility the resulting data was made available to the researcher for the purposes of this study. The data was given on aSatisfaction Survey 45 disk and was only de-identified that was coded upon receipt and entered into an SPSS database. This coded data is what was used for analysis in this study. Human Rights Protection For the purposes of this study an exempt Institutional Review Board application was submitted and approved by D*Youville College. There was a pre- existing data set made available from a western New York surgery center which ‘was analyzed. The data shared with the researcher was anonymous; there was no way for the researcher to determine the identity of the patient who participated in the survey without access to the facility’s practice management software program. The facility which participated in this research had been collecting patient satisfaction data for several years and will continue to do so. Treatment of Data Descriptive statistics were utilized to summarize demographic data ‘Number and percent were extensively employed for the purposes of examining categorical data, The quality indicators and overall satisfaction levels were addressed by calculating the mean, standard deviation, minimum and maximum. To compare the demographic statistics with the quality indicators and overall satisfaction inferential statistics were used specifically linear regression. Summary This chapter provides the description of the setting where the original information was collected. The population and sample of the accessible population used to obtain the data that was made available to the researcher wasSatisfaction Survey 46 expressed, The methods for the collection of the original data were described, followed by the process of the researcher obtaining and coding the existing data. ‘A description of the human rights protection was given followed by an explanation of how the data that was shared with the researcher was analyzed.Satisfaction Survey 47 CHAPTER IV ANALYSIS OF DATA Introduction In this chapter, the results from analyzing the data for this exploratory study will be imparted. Descriptive statistics were utilized to analyze patient satisfaction in the participating ambulatory surgery center based around quality indicators present in the literature base. In addition, inferential statistics were used to explore the influence of specific demographic characteristics on patient satisfaction. Description of the Sample The target population for this research consisted of the patients being treated in an ambulatory surgery center environment. A westem New York facility agreed to make results of their patient satisfaction survey available for study and analysis. A convenience sample of the target population was identified and data was collected between the dates of July 16-20, 2007 and August 13-17, 2007. The sample data resulted in 216 returned surveys from the original 358 given out for a total response rate of 60%. Of the retumed surveys for analysis purposes those with missing data were not removed from the sample. Those who responded to the survey were varied relating to their marital status, the majority of the respondents were married (60%), followed by widowedSatisfaction Survey 48 (19%), single (13%), divorced (796) and finally separated people responded least (1%). More females responded (65%) than males (34%). Respondents were more likely to be visiting the participating surgery center for the first time (66%) than to have been there for a procedure before (34%). Those with a high school diploma were also more represented (59%) than those who have received a bachelors degree (19%) or a masters degree or beyond (12%) and least represented was the population with less than a high school education (7%). The mean age of the population was skewed toward the older end with a mean age of neatly 63 years Household income characteristics were calculated based on the geographic area of where the respondent lived. The results ranged from $24,536.00 to $68,003.00 annually. Demographic characteristics relating to the nature of the type of visit and treating physician were varied. Table 3 illustrates the specific surgeon the patient was being treated by, with a range of specialties identified in table 4, dominated by ophthalmology (54%) followed by plastic surgery (16%), orthopedics (13%), pain ‘management (7%), ear, nose and throat (6%) and least represented was podiatry 0%),Satisfaction Survey 49 Table 1 Descriptive Statistics- Demographic Characteristics Frequency Percent Maral Stas Married 129 6 Divorced 16 1 Single 27 B Separated 2 1 Widowed 41 19 Total 215 100 Gender Male 7 34 Female 141 66 Total 214 100 First Visit Yes 142 66 No B 34 Total 215 100 Education Level Less than High School 16 8 High School Graduate 128 60 Bachelors Degree 2 20 Masters and Beyond 26 R Total 212 100Satisfaction Survey 50 Table 2 Descriptive Statistics- Age and Income of Respondents — Mean Min Max Re@=2) 6 19 3 8 Income (n = 216) $41,792.55 $12,588.18 _$24.536.00 $68,003.00Table 3 Satisfaction Survey 51 Descriptive Statistics- Surgeon Performing Procedure (n = 216) Frequency 1 12 13 14 15 16 75 76 82 85 88 90 91 92 94 98 109 110 ut 114 115 133 185 195 197, 297 298 304 310 Total * % not =100 due to rounding 1 2B 10 5 12 Percent™Satisfaction Survey 52 Table 4 Descriptive Statistics- Area of Surgeon Specialty (n=216) Frequency Percent™ “Opthomology—=“~*‘*~*«ST oa Orthopedics 29 13 Ear, Nose, Throat 13 6 Plastic Surgery 35 16 Pain Management 16 7 Podiatry 6 3 Total 216 99 * % not =100 due to roundingSatisfaction Survey 33 Research Questions This study answered the following research questions: Research question one: what is the overall level of satisfaction in patients utilizing ambulatory care centers? Respondents were asked to rate their level of satisfaction by recording on a five-point likert style scale ranging from strongly agree to strongly disagree their opinion on twenty questions relating to the four quality indicators. The questions were written in a positive in nature, thus agreeing with the statement was favorable and disagreeing was unfavorable. The following table displays the responses from the patients to all twenty questions. Based on the results an overall satisfaction level of 97% can be determined by combining those respondents who strongly agreed (91%) or moderately agreed (6%) with the questions. Research question | is addressed in table 5.Satisfaction Survey 54 Table 5 Overall Patient Satisfaction- Responses to all Questions Strongly Agree Moderately agree Neutral Moderately Disagree Strongly Disagree % # % 2 1% 7 az 200 93 «186 as 199 «6920 157 OG lose 0 116) 7, a5 206 9 «89 4 as 159 74 33 t! a7 193 «89 «178 Og (ee ee 1 ao 207 96 «84 iO) 106) Cl 10) 4 4 5 5 6 1 3 im 1 1 Qi 205 96 8 Gig) 2001 ise 204 05) if Qi4 205 95 = 10 Qs 199 «9314 Qi 18 «88 «= 20 Che Cy 0 aig 199 «9315 aig 190 900 2t Cy a) tee 6 eee fe ce oe cies | OMAN AOHOMMORNIO OOO?" moveen ccc cece msc04048| Avge a & 7 3 aSatisfaction Survey 55 Research question two: what is the level of satisfaction in patients utilizing ambulatory care centers within each quality indicator? To determine the satisfaction level relating to each of the quality indicators the responses were broken down into categories based on the quality indicator they related to (Table 6). The following table displays the responses by quality indicator, including nursing care, communication, environment and outcomes. Mean, standard deviation, minimum and maximum for each quality indicator was calculated and displayed. The results suggest that with respect to the quality indicator of nursing care mean satisfaction rate of the responses was 5.40 or 93%, for the quality indicator of communication the mean satisfaction rate was 5.81 or 86%, 5.26 or 95% for the environment of the facility and finally in reference to outcomes following the procedure the satisfaction rate was 5.79 or 86%,Satisfaction Survey 56 Table 6 Patient Satisfaction by Quality Indicator N Minimum Maximum Mean Std. Deviation Nursing Care —~SCG 5 13 S40 127 Communication 201 5 12 5.81 1.49 Environment 210 5 10 5.28 ost Outcomes: 201 5 16 5.79 1.72 Total Ql 184 20 49 22.17 418Satisfaction Survey 57 Research question three: what is the relationship of area of physician specialty, physician, age, gender, socioeconomic status, marital status, repeat visit and education level on overall satisfaction in patients utilizing ambulatory care centers? Inferential statistics relating overall satisfaction to demographic characteristics were determined using the method of regression (Table 7). The following table displays all of the demographic characteristics and shows their relationship to overall satisfaction. When looking at total satisfaction the demographic characteristic that showed a statistically significant relationship to satisfaction is ifthe patient is a first time patient at the facility with a significance ofp=.021.Satisfaction Survey 58 Table 7 Multiple Regression: Demographic Characteristics and Total Satisfaction Beta t Sig. 95% Confidence Interval for B Marital Status 080 1.021 309 -.187 589 Gender -.085 1.090.277 -1.987 S74 First/Repeat ~-184 2331 021° -2.809 -.233 Visit Education -.040 -524 601 -.942 S47 Level Age 092 1015312 -019 058 Specialty 102 Lud 267 -.204 733 Doctor 001 016 987 -.008 008 Income = 112 1456147 .000 000 * ps.05 n= .063Satisfaction Survey 59 Research question four: what is the relationship of area of physician specialty, physician, age, gender, socioeconomic status, marital status, first/repeat visit and education level within each quality indicator in patients utilizing ambulatory care centers? The inferential statistical analysis method used to measure this relationship was regression analysis. The following tables display all of the demographic characteristics and shows their relationship to the quality indicators of nursing care (Table 8), communication (Table 9), Environment (Table 10) and Outcomes (Table 11). For the quality indicator of nursing care a relationship emerged between first/repeat visit and satisfaction level with a significance of |__p = .023, Communication showed a relationship to income with a significance of p = .021. The final two quality indicators, environment and outcomes showed no significant relationship to any of the demographic characteristics. The answers to research question 4 is addressed in tables 8-11Satisfaction Survey 60 Table 8 Multiple Regression: Demographic Characteristics and Nursing Care Beta Sig. 95% Confidence Interval for B Marital Status 086 ihi72) 243 -.046 181 Gender 036 502 616 -278 467 FirsRepeat -166 -2.286 023+ -81l -.060 Visit Education -.008 oA 912 ~230 205 Level Age 7 1.465 145 -.003 018 Specialty 3 1413 159 -.036 219 Doctor -.019 +260 795 -.003 002 Income -.106 -1.488 138 000 000Satisfaction Survey él Table 9 ‘Multiple Regression: Demographic Characteristics and Communication Beta Sig. 95% Confidence Interval forB Marital Status 039 ~512 609 ~175 103 Gender +013 =168 867 -503 425 First/Repeat 124 1.656 099 -.843 074 Visit Education 048 652 SIS ~.182 361 Level Age 072 835 405 =.008 019 Specialty 039456649 -126 201 Doctor ~004 — -.047 962 ~.003 003 Income 172-2324 021* 000 000 * ps.05 n= .063,Satisfaction Survey 62 Table 10 Multiple Regression: Demographic Characteristics and Environment Beta 95% Confidence Interval forB Marital Status a Ge --102 037 Gender -044 610-542 -342 180 FirstRepeat 113-1541 125, -AT2 058 Visit Education sl 1.137.257 -.064 239 Level Age 114 1.402162 ~.002 013 Specialty -049 --596 552 -119 064 Doctor 09 1471143 000 .003 Income 051-716 ATS 000 .000 05 n= 063Satisfaction Survey 63 Table 11 Multiple Regression: Demographic Characteristics and Outcomes Beta ig. 95% Confidence Interval ____ for B Marital Status 025 321 749 =133 185 Gender -047— -.617 538 -687 360 FirstfRepeat -024 — -306 760 -615 450 Visit Education -025~331 TAL -356 254 Level Age 043 502 616 -011 019 Specialty ~009 — -.102 919 =191 AR Doctor 072918 360 ~.002 005 Income -005 — -.065 948 000 000 * ps.05 n= 063,Satisfaction Survey 64 Data Collection Tool A pre-tested questionnaire that was developed by the participating facility was used to collect patient satisfaction data, The results of the survey were shared for the purpose of this research to assist in answering the research questions presented in this study. The anonymous data was coded and entered into SPSS with the purpose of performing statistical analysis of the data, The tables and charts created and integrated into this study were created out of the SPSS data, The survey responses were anonymous to the researcher who assigned a number to each response. These numbers reflect the position of the respondent in the SPSS spreadsheet. The responses of each individual were coded as variables in SPSS to be analyzed statistically by demographic and inferential methods. Summary ‘The survey results which were shared for the purpose of this research were collected by distributing the survey in person to be returned by mail. The responses were rich with demographic data which was displayed in tables in this chapter. The responses also led to the ability to address all of the research questions presented for this study. The responses were analyzed using SPSS and ‘were presented in various tables. Number and percent were used to analyze research question 1, mean median and standard deviation were used for research question 2 and inferential statisties in the form of regression were used to analyze research questions 3 and 4. The factor of first time visit status was shown to have a statistically significant correlation with overall satisfaction. This factor also hadSatisfaction Survey 65 a correlation with nursing care, while communication showed a statistically significant correlation with incomeSatisfaction Survey 66 CHAPTER V RESULTS. Summary Health care is a field of study that continuously grows and changes. Research must keep up with the changes and constantly adapt to fit the needs of new and emerging areas within health care. In recent years there has been an increase in the number of surgical procedures that can be performed on an outpatient basis, This shift has led to the emergence of specialized ambulatory care facilities that deal exclusively with procedures that do not require an inpatient stay overnight. As technology continues to adapt and become more advanced the procedures that can be done on an outpatient basis will continue to ‘grow as well as the number of specialized facilities. A unique measurement tool targeted specifically at the care provided in these types of facilities is needed. A ‘western New York area surgery center greed to share the results of their survey with the researcher for the purposes of this exploratory study. The purpose of this study has been to identify levels of patient satisfaction within the participating facility as an overall measure and with respect to specific quality indicators, In addition, the demographic characteristics that could influence patient satisfaction were identified and measured,Satisfaction Survey 67 ‘The theoretical framework that served a basis for this research is grounded in general system theory. This theory was first developed by Ludwig von Bertalanffy in 1968, and later adapted for healthcare by Joan Gratto Liebler and Charles R. McConnell in 2004. The general concept is that a facility functions like an organism, with parts and systems that work in unison to create a homeostasis within the being, If one system or part is malfunctioning or out of line with the others it will create an imbalance and affect the entire organism. The same is true of @ health care facility; if one area within the facility falters, the effects are felt throughout, The goal is for the facility to have the ability to identify what areas are not satisfactory and target them with an improvement initiative, the results of which will be seen by the entire facility. The process of obtaining feedback and cyclical re-measurement makes this concept realistic for continuous use within a facility. The review of literature focused on main topics which related to this research. Quality indicators of nursing care, communication, environment and ‘outcomes were identified and studied for support in the literature base. Demographic characteristics were identified in the body of research and the support for their measurement was identified. The process of surveying, as well as survey methods and alternative tools were researched to support the tool that is being used in the participating facility. The surveys were distributed by the participating surgery center through the period of July 16-20, 2007 and August 13-17, 2007. The sample data that wasSatisfaction Survey 68 released to the researcher resulted from 216 surveys that were retumed to the facility. Descriptive statistics were used to summarize demographic data, number and frequency were used to report categorical data, mean, standard deviation, ‘minimum and maximum were used for continuous data and comparative statistics in the form of regression analysis were also employed Conclusions The conclusions of this study are discussed as they relate to: the conceptual framework, literature, research questions, variables, study design and data collection methods, the tool used and the statistical and data analysis methods. Relationship of the Results to the Conceptual Framework ‘The conceptual framework for this study was general system theory as it was first developed by Ludwig Von Beralanfly in 1968 and then as it was interpreted for the field of healthcare by Joan Gratto Liebler and Charles R. McConnell in 2004. The general concept of this theory revolves around the fact that a facility can be studied not only as a whole, but also as individual parts. Examining a facility on this level enables the researcher to target and make specific recommendations targeted to those specific parts, As a result, these changes in one part of the facility will have an impact on the whole. In line with the diagram for system theory as developed for this research Fig. 3), the throughputs of nursing care, communication, environment and outcomes were identified and studied. The outputs were the responses of theSatisfaction Survey 69 patients on the survey distributed by the facility. The response is the process by which this researcher interprets the outputs and presents them to the management of the facility, indicating specific arcas where change may result in increased satisfaction, The response from the surveys resulted in an overall satisfaction level of 97%. The response as it relates to each of the throughputs is can also be determined. The satisfaction level relating to nursing care was 93%, communication was 86%, the environment of the facility was 98% and the satisfaction with respect to patient outeomes was 86%. The feedback loop in this case is the process by which the participating facility initiates changes that influence these areas of satisfaction. In this case, the most room for improvement lies in the throughputs of communication and outcomes. The facility can interpret these results and implement changes that they feel could impact these levels in a positive way. The ability to re-survey the population to measure for the effectiveness of the changes is a useful way of ensuring that the changes ‘implemented are having the desired effect. System theory is a cycle, and by designing the framework of this study around a cyclical model, the facility involved can continue to measure and make changes at will. Relationship of the Results to the Literature ‘The relationship of the results from this study to those studies found in the literature base showed both similar results as well as different. Many of the studies presented in the literature showed high levels of satisfaction. In a study conducted by Wall et al. in 2007 utilizing the FS-ICU tool there was a total levelSatisfaction Survey 0 of satisfaction of 85.4%. One study utilized a likert scale ranging from 1-5 to ‘measure patient satisfaction, much the same as the too! used for this study. The ‘mean satisfaction to most questions was above a 4.0 and fell between satisfied (4) and very satisfied (5) (Dansky et al., 1996) For this exploratory study the results were similar, with 97% of the results falling between 4 and 5, with 91% total being responses of 5, strongly agreeing with the satisfaction questions. A 2002 study conducted by Yellen et al. utilizing the PSI tool showed patient satisfaction score that was negatively skewed, meaning that the majority of the responses indicated that patients were satisfied or very satisfied. The results of this study were also skewed negatively as the positive responses were very high, with a total satisfaction level of 97%. One example from the body of literature also specifically studied satisfaction with nursing care, and showed a satisfaction level of 77% relating specifically to that area (Ocrmann, 1999). In this study the satisfaction with nursing care was even higher with a level of 93%. Certain trends emerged in the literature relating to demographic characteristics. In several of the studies in the literature base the population who responded was skewed towards older rather than younger with average ages of respondents including 51 yrs (Oermann & Templin, 2000), 62 yrs (Langemo et al,, 2002). The population studied in this study was also skewed toward older with amean age of 63yrs. With respect to age and satisfaction levels, age has been. positively associated with levels of satisfaction in the literature. This means that older people are more likely to give a positive account of their experienceSatisfaction Survey 1 (McHorney & Fleishman, 2006). This trend was observed in other studies in the body of literature. In a study conducted by Elaine Yellen in 2003 older people ‘were shown to have higher levels of satisfaction with pain management. Higher levels of overall satisfaction were also shown among older populations when compared to younger (Langemo et al., 2002). One study was found, conducted by Wall et al. in 2007 which showed no significant age differences relating to satisfaction levels. For this study, a regression analysis performed indicates that the same is true for this population, there were no significant findings that age was correlated with satisfaction. Gender is another demographic characteristic that is frequently studied in many studies found among the literature. The response results from one study showed that females made up a larger percentage of the respondent population, (63%) than males (37%) (Oermann & Templin, 2000). For this study the population was also made up of more females (65%) than males (34%). Correlations between gender and levels of satisfaction were observed in cases, where males were more satisfied than females (Yellen, 2003). There were also examples where no correlation could be drawn between gender and satisfaction levels (Wall et al,, 2007, Langemo et al. 2002, Dansky et al., 1996). The latter results, where no correlation of statistical significance could be determined is the same result that was derived using regression analysis for this study.Satisfaction Survey vd Relationship of the Results to the Research Questions The first research question targeted the measurement of the overall level of satisfaction among the patient population. The overall level of satisfaction was determined by adding the percentage of respondents who strongly (91%) and. moderately agreed (6%) with the positively phrased questions. This resulted in an overall satisfaction level of 97%, The second research question broke down the level of satisfaction into the four quality indicators. Nursing care, from a skill perspective includes technical, interpersonal and educational aspects of care. From the patient perspective, nursing care involves concer for comfort and respectful interactions. The results of the data analysis showed a satisfaction level of 93% among the patient population as it relates to nursing care. The second quality indicator examined in this study is communication, Wait times, telephone accessibility and consenting to and receiving the correct procedure were found to be important to the patient relating to communication. The level of satisfaction with communication that resulted from the data analysis is 86%. The environment of the facility was the third indicator studied relating to satisfaction of patients. The environment includes cleanliness, safety, staffing levels and privacy. These specific areas were measured on the tool distributed by the facility, ands the result was an overall level of satisfaction with the environment of 98%. The final quality indicator that ‘was examined in this study was outcomes following surgery. Outcomes relative to outpatient surgical procedures include the rate at which patients can return toSatisfaction Survey 2B normal activities of daily living, adherence to post-operative care recommendations, adverse effects following a procedure and complaints. These specific topics within outcomes were measured on the tool distributed by the facility and resulted in an overall satisfaction level of 86% with respect to this, quality indicator. All of the statistics relating to each quality indicator were calculated utilizing the mean statistic function in the SPSS data analysis software program. The third research question explores the relationship of the various demographic characteristics and total satisfaction. The only demographic characteristic that showed a statistically significant correlation with overall satisfaction was repeat visit (p = .021). The final research question broke down the relationship into each quality indicator as they related to demographic characteristics, This question was answered using regression analysis which determined that nursing care was correlated with repeat visit (p = .023) and communication was correlated with socioeconomic status (p = .021). The other ‘two quality indicators environment and outcomes showed no significant relationship with any of the demographic characteristics when analyzed using regression analysis, Relationship of the Results to the Variables There were two types of variables examined in this study, independent and dependent. The independent variables were measured on the survey tool distributed by the participating ambulatory surgery center. The first variableSatisfaction Survey 4 measured was area of physician specialty, which was represented most by ophthalmology (54%) followed by plastic surgery (16%), orthopedics (13%), pain management (7%), ear, nose and throat (6%), and lastly podiatry (3%). The results of the regression analysis comparing this variable to satisfaction levels showed no statistically significant correlation. The physician who performed the procedure was also measured as an independent variable, The results showed that, 29 surgeons were represented to varying degrees (Table 3). When a regression analysis was performed comparing this variable to patient satisfaction levels, no statistically significant correlation was found. The third independent variable measured was age. The mean age of respondents was 63 yrs, with a standard deviation of 19 yrs, a minimum of 3 yrs and a maximum of 89 yrs. A regression analysis was performed to determine if a correlation exists between age and patient satisfaction levels which resulted in the conclusion that there is no significant correlation in this study. Gender was also measured for this study as an independent variable. Of the respondents 34% were male and 66% were female, ‘When this variable was compared to satisfaction levels using regression analysis no statistically significant correlation was found. Socioeconomic status was also ‘measured as an independent variable represented by income level based on geographic location. The mean income was $41,792.55 with a standard deviation of $12,588.18, a minimum of 24,536.00 and a maximum of 68,003.00. When this variable was compared to overall patient satisfaction there was no correlation found, however when compared to the individual quality indicators income wasSatisfaction Survey 75 positively correlated with communication (p = .021). Another independent variable which was measured is marital status. Of the responding patient population 60% were married, 19% were widowed, 13% were single, 7% were divorced and 1% were separated. When a regression analysis was conducted relating this variable to levels of patient satisfaction, no significant correlation was found. Repeat visit was another independent variable that was measured for. Of the responding patient population 66% were first time patients while 34% had been to the facility at least one time before. The regression analysis that was performed on this variable showed a positive correlation between repeat visit and total satisfaction (p = .021) as well as between repeat visit and the quality indicator of nursing care (p= . 23). This means that patients who had been to the facility at least one time before were more satisfied than those for whom it was their first visit. The final independent variable measured for was education level. Of the responding population 60% identified themselves as high school graduates, 20% had achieved their bachelors degree, 12% had an education level of masters or beyond and 8% had less than a high school education. The results of a regression analysis performed comparing education level to satisfaction levels showed no statistically significant relationship between the two. ‘The other kind of variables that were measured for in this study are dependent variables. Overall satisfaction was measured for and found to be at 97%, Satisfaction levels with respect to the quality indicators that emerged through the literature were nursing care (93%), communication (86%),Satisfaction Survey 16 environment (98%) and outcomes (86%). The dependent variables were also used in various regression analyses to determine significant relationships. Total satisfaction was found to have a statistically significant relationship to repeat visit (p=.021), communication was found to have a statistically significant relationship to income (p= .021) and nursing care was found to have a significant relationship with repeat visit (p = 023) Relationship of the Results to the Study Design and Data Collection Methods The results that emerged in this study relate very directly to the data collection method. The questions that were asked on the survey that was distributed by the participating facility provide a direct basis for statistical measurement. Results from survey questions 1 through 20 showed levels of overall patient satisfaction as well as levels of satisfaction relating to each of the quality indicators identified through the research. They also provided the source for dependent variable measurement data which was used in combination with the demographic data collected from page two of the tool as well as the top right comer of page one. The demographic data and the answers to questions 1 through 20 were analyzed for statistically significant relationships using regression analysis. The results showed a statistically significant relationship between overall satisfaction and repeat visit, a significant relationship between nursing care and repeat visit and a significant relationship between income and communication.Satisfaction Survey 1 Relationship of the Results to the Data Collection Tool ‘The survey designed and distributed by the participating ambulatory surgery center (Appendix B) resulted in a sufficient response rate for all of the questions proposed for study in this research. The responses that resulted were overwhelmingly positive leading the researcher to believe that the use of more sensitive questions in the survey could lead to more varied results, providing better comparison data. Relationship of the Results to the Statistical and Data Analysis Methods The data from the 2007 survey distributed by the participating ambulatory surgery center released was coded. Both categorical and continuous data were included in the analysis, which led to the use of varying methods for analysis that ‘would be suitable to each type of data. Continuous variables were analyzed utilizing mean, standard deviation, minimum and maximum. Categorical variables were represented with number and percent statistics. Finally, regression analysis ‘was used to compare independent and dependent variables to determine if relationships exist between these variables. Implications for Practice, Management, or Education The results of this study provide valuable data for quality improvement to the participating facility. The overall satisfaction level of 97% is very high, so high that examining only the overall score would not lead to much in the way of improvement initiatives. However, when examining the satisfaction levels with respect to the quality indicators more room for improvement can be identified.Satisfaction Survey 8 The results of the data analysis showed a satisfaction level of 93% relating to nursing care. This statistic shows that although the score is high, there is room for improvement from the perspective of the patient. Depending on what the facility determines the acceptable level of satisfaction to be relating to this quality indicator, new procedures may be considered by the facility involved to improve this level. The regression analysis showed that repeat visit is correlated positively with nursing care. This researcher would recommend that if an improvement initiative is integrated within the facility that it be targeted toward first-time patients to obtain the greatest result. ‘The level of satisfaction relating to communication that resulted from the data analysis is 86%. This statistic indicates that there is quite a bit of room for improvement with this aspect of care within the facility that participated in the study. By breaking the results down even further in order to determine a specific area to target with an improvement initiative the results to question six on the survey relating to wait time had the lowest score. By integrating a new system to reduce wait times, such as an alteration in the scheduled procedure times or a change in the environment, policies or procedures that leads to a decreased, perception of waiting, there is a possibility for a noticeable impact on patient satisfaction levels relating to communication. The level of patient satisfaction with the environment of the facility is 98%, This level is very high, nearly perfect. The facility may want to replace this portion of the survey tool with questions relating to a different quality indicatorSatisfaction Survey 9 present in the literature base, and continue to maintain the environment of the facility as itis currently. There are many potential areas within a facility that can bbe measured and finding one area that excels does not mean that it should continue to be measured simply because itis rewarding to see this high level of success. It would better benefit the facility to measure another area, where there may be more room for improvement and thus a greater impact on the overall satisfaction. The level of patient satisfaction with outcomes from their procedure is 86%. This is a statistic that has room for improvement, and is probably not as. high as the goal the facility has for this area. Within the questions, specifically question 16, relating to recovery period expectations and question 20 relating to patient and family complaints showed the most room for improvement. The researcher feels that the wording of question 20 may have contributed to the negative responses. The researcher would propose re-phrasing the question to fit the format of the other questions (which are all positive in nature). The facility may consider putting new policies in place relating to the explanation of what the patient can expect during their recovery period, Often the duty of informing patients of possible risks, complications and pain following surgery is left in the hhands of the physician. However, as so much information and personal contact comes from the nurse in the ambulatory surgery environment perhaps utilizing that relationship could help the patients understand what is to come. Perhaps the distribution of more detailed post-operative instructions relating to the recoverySatisfaction Survey 80 process would also be beneficial. The researcher would then recommend re- measuring to see if there has been a noticeable improvement since the new procedures have been integrated. Recommendations for Future Research Researcher would recommend some improvements to the process that ‘would be beneficial for future research. The survey results are limited in scope of impact because only one facility was involved. The sample size was good, based on the large patient population of the facility, however involving multiple facilities would provide valuable comparison data and support for the tool used. Researcher would also recommend eliminating the questions based on the environment of the facility and integrating questions that relate to a different quality indicator as the results for the environment left little room for improvement or growth of the facility. The reason for the large amount of demographic characteristics present on the survey is to determine which ones may impact satisfaction. Now that the results indicate what few characteristics impact satisfaction the tool can be re-worked to only include those characteristics that were statistically significant. This would be a recommendation to the participating facility, however, ifthe survey is distributed at multiple measuring for more demographic characteristics may provide more valuable data for future research. Through the survey and re-survey, process healthcare facilities have the ability to increase loyalty, patient retention and implement many more significant changes that come as a result of the outcome. Because of this the researcher wouldSatisfaction Survey 81 recommend frequent changes to the tool, improvement initiatives within the facility and continuous re-surveying to measure their impact. The results of the examination of this survey not only empower the participating facility with knowledge, but they indicate what should be measured and better ways to measure it.Satisfaction Survey 82 References Amin, A., & Owen, M. (2006). Productive interdisciplinary team relationships: The hospitalist and the case manager. Lippincott's Case Management, 11(3), 160-164. Anthony, M., & Higgins, P. (2006). Maximizing the utility of interorganizational data using concept mapping. The Journal of Nursing Administration, 36(5), 233-240. Bebbington, P., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., & Meltzer, H. (2003). The influence of age and sex on the prevalence of depressive conditions: Report from the National Survey of Psychiatric Morbidity. International Review of Psychiatry, 15, 74-83 Bostick, J., Riggs, C., & Rantz, M. (2003). Quality measurement in nursing: An update of where we are now. Journal of Nursing Care Quality, 18(2), 94+ 104. Coventry, W.L., Gillespie, N.A., Heath, A.C., & Martin, N.G. (2004). Perceived social support in a large community sample. Social Psychiatry and Psychiatric Epidemiology, 39, 625-636. Dansky, K., Colbert, C., & Irwin, P. (1996). Developing and using a patient satisfaction survey: A case study. Journal of American College Health, 45, 83-89. Eilers, G. (2004). Improving patient satisfaction with waiting time. Journal of American College Health, 53(1), 41-43.Satisfaction Survey 83 Gandhi, T., Francis-Cook, E., Louise-Puopolo, A., Burstin, H., Haas, J., & Brennan, T. (2002). Inconsistent report cards: assessing the comparability of various measures of the quality of ambulatory care. Medical Care, 40(2), 155-165. Gold, M., & Wooldridge, J. (1995). Surveying customer satisfaction to assess managed-care quality: Current Practices. Health Care Financing Review, 16, 155-173. Griffin, K., & Swan, B. (2006). Linking nursing workload and performance indicators in ambulatory care. Nursing Economics, 24(1), 41-44. Grundman, R. (2007). Various Postings and Publications from www.aaahe.org. Skokie, Illinois: AAAHC. Langemo, D., Anderson, J., & Volden, C. (2002). Nursing quality outcome indicators: The North Dakota Study. The Journal of Nursing Administration, 32(2), 98-105. Larrabee, J. (1996). Emerging model of quality. The Journal of Nursing Scholarship, 28(4), 353-358. Liebler, G., & McConnell, C. (2004). Management Principles for Health Care Professionals, Fourth Edition, Sudbury Massachusetts: Jones & Bartlett. McHomey, C.A., & Fleishiitan, J.A. (2006). Assessing and understanding measurement equivalence in health outcome measures. Results: Medical Care, 44(11), 205-210.Satisfaction Survey 84 Oermann, M., Lambert, J., & Templin, T. (2000). Parents’ perceptions of quality health cate. The American Journal of Maternal/Child Nursing, 25(5), 242- 247. Oermann, M., & Templin, T. (2000). Important attributes of quality health care. Journal of Nursing Scholarship, 32(2), 167-172. Reed, L., Blegen, M., & Goode, C. (1998). Adverse patient occurrences as a ‘measure of nursing care quality. The Journal of Nursing Administation, 28(5), 62-69. Sawyer, L., Berkowitz, B., Haber, J., Larrabee, J., Marino, B., Martin, K., Mason, K., Mastal, M., Nilsson, M., Walbridge S., & Walker, M. (2002). Expanding American nurses association nursing quality indicators to community-based practices. Outcomes Management, 6(2), 53-61. Shindul-Rothschild, J., Long-Middleton, E., & Berry, D. (1997). Ten keys to quality care. American Journal of Nursing, 97(11), 35-43, Stacy, N., & Richman, C. (1997). Person perception as a function of marital status and age. The Journal of Social Psychology, 137(3), 395-397. Swan, B., Conway-Phillips, R., & Griffin, K. (2006). Demonstrating the value of the RN in ambulatory care. Nursing Economics, 24(6), 315-322. von Bertalanffy, L. (1968). General System Theory: Foundations, Development, Applications, New York: Braziller.Satisfaction Survey 85 Wall, R., Engelberg, R., Downey, L., Heyland, D., & Curtis, J. (2007). Refinement, scoring and validation of the family satisfaction in the intensive care unit survey. Critical Care Nursing, 35(1), 271-279. Yellen, E. (2003). The influence of nurse-sensitive variables on patient satisfaction, AORN Journal, 78(5), 790-793. Yellen, E., Davis, G., & Ricard, R. (2002). The measurement of patient satisfaction, Journal of Nursing Care Quality, 16(4), 23-29,Satisfaction Survey 86 Appendix A Institutional Review Board Full Approval LetterSatisfaction Survey 87 (716 920-8000 Fax. 716) 8207700 foe ante etnt : Dr. Mark Garrisonn@\, Institutional Review Board November 20, 2007 " SUBJECT: IRB FULL APPROVAL I am pleased to inform you that your application to the fs Bi¥ouville College Institutional Review Board entitled: "A Survey Of Patient Satisfaction In The Ambulatory Surgery Environment Utilizing Quality Indicators" has been granted FULL APPROVAL with respect to the protection of human Subs Tis means that you may now begin your research unless you must first apply to the IRB at the institution where you plan to conduct the research. Please note that you are required to report back to this IRB for further review of your research should any of the following occur: 1. ‘a major change in the method of data collection 2. unanticipated adverse effects on the human subjects 3. unanticipated difficulties in obtaining informed consent or maintaining confidentiality 4, the research has not been completed one year from the date of this letter Congratulations and good luck on ydur research! ja, cet Director of Graduate studies Dr Walter Iwanenko 320 Porte Avenue Buta, Naw Yor 4201-1088 en seeSatisfaction Survey 88 Appendix B QuestionnaireSatisfaction Survey 89 Patient Satisfaction Survey Physician liz wourd help us to know. Date of procedure [Please check the box that best suits your lagreement with the following statements... y Moderately Strongly Agree [Agree Disagree ~The nursing staff was concemed with a a a my comfort 2. The nursing stat? listened to o a 0 me effectively 3. The nursing staff appeared to be skilled and 9 a a o a knowedgeable : y |4. | was satisfied with the explanation of oO ao oO o a ‘my post-operative instructions, 5. | was treated with respect by the nursing staff o o o o o Jb. The time | experienced in the waiting room B 0 a 0 oD was acceptable 17. While | was at the center my questions o a 5 a oD of concerns were answered to my satisfaction 8. Over the telephone my questions or concems a a 0 a D were answered to my satisfaction 9. | received the correct procedure without a a a 0 B confusion 10. l understood what was going on throughout a a a 5 o my experience 11. The staff I was surrounded by were caring people | o a o a 12. The faciity had enough staff to give me the 5 o 5 o 3 attention that | needed. 13. 1 was treated with friendliness and respect o o o 9 o by the office staff 14. The physical envionment of the faciity -* | o a a 0 a was well maintained 15. Throughout the facility the staff appeared. 0 a a a o to work together 16. My recovery period was what | expected 0 5 0 0 5 * |17. Lwould have no reservations about returning o . o 0 o to this facity for another procedure 18. The post-operative instructions were o oD o a o 89 to follow 19. 1 was prepared for the physical healing a a o a 0 process following my procedure 20. | (or my accompanying party) felt the need 2 0 o o a to register a complaint ‘OVER —————>Satisfaction Survey 90 Please tell us a few things about yourself... JAre you? lo Married 1s Divorced fn Single Io Separated 1a Widowed [Are you? sa. a Mate Ia Female [This was my first visit to the Ambulatory Surgery Center of Western Now York la Yes Io No |What is your level of education? jo Less than high school jo High school graduate Ic Bachelors Degree I> Masters or beyond How old are you? . Please enter your Zip Code Thank you for your time, your responses help us serve you the best we can!Satisfaction Survey a1 Appendix C Letter of Permission to Share DataSatisfaction Survey 92 June $, 2007 Dr. Walter Iwanenko Chair- Health Services Administration 320 Porter Ave. Buffalo, NY 14201 Dear Dr. Iwanenko, Please accept this letter as authorization to allow HSA Graduate student Melinda ‘Tabbi to have access to our data which has been collected from our previously distributed patient satisfaction surveys. This data is permitted for use in ber Graduate thesis on the topic of patient satisfaction in ambulatory surgery centers. She has our permission to share this data in the form of her thesis for D'youville College. Sincerely, Joan Dispenza ; Administrator