National Nurses United

CE 2_Nov REV 12/10/10 8:16 AM Page 22 statement: "…those institutions that react quickly and comprehensively can turn higher patient satisfaction into a clear competitive advantage in the marketplace." The new CMS criteria along with aggressive marketing from companies such as the Studer group and Press Ganey have resulted in hospitals experiencing "market anxiety," leading to a clamoring for new ways of improving patient satisfaction. This "market anxiety" leads to less-than-critical thinking on the part of the hospital administrators and so-called nurse leaders, whereby they become easy prey for outside consulting groups to come into their facilities to "train" their staff on these new schemes. Since their pay and personnel evaluations are often conditional on successful implementation of these schemes, management has a vested, personal self-interest in promoting adoption and could be biased toward reporting positive outcomes, which makes the data and its interpretation highly suspect and unreliable. Of course these rounding schemes are endorsed and promoted by the same corporations and hospitals that stubbornly fight against improving nurse-to-patient ratios or attempt to replace RNs with lesser-skilled healthcare workers. According to Dr. Christopher Guadagnino, in a December 2003 article he wrote for Physician's Digest News, "variation in measurement tools is an obstacle to making patient satisfaction a reliable part of the quality equation. Even if redundancy and variation of patient satisfaction measurement can be minimized to permit meaningful comparison across providers, questions remain…whether it is even appropriate to consider patient satisfaction as a valid clinical quality indicator." A recent Institute of Medicine report outlined six characteristics of quality healthcare: safe, equitable, evidence-based, timely, efficient, and patient centered. Lack of comparability of patient satisfaction data remains an obstacle to its expanded use. Measured by different entities, for different purposes, using different instruments, patient satisfaction data is far from uniform. In a December 2003 interview also reported in Physician's News Digest, Carey Vinson, medical quality director for Blue Cross-Blue Shield, said, "Patient perception data about clinical processes and outcomes may lack validity, and not many tools currently exist to measure what is going on inside a hospital or a physician's office." According to Dr. Marshall Webster, MD, president of the University of Pittsburgh Medical Center's Physician Services Division, and president of UPMC's physician services, "measurements (surveys) are best kept to the quality of service side rather than become integrated with the quality of care issues. I don't think the Press Ganey survey is the kind of instrument that is helpful for us in looking at very objective measurements of quality of care. We want specific, objective, measurable things that attest to the quality of care that we are providing—for example, one year survival after liver transplants." One obvious method of improving patient satisfaction as well as patient outcomes would be to improve nurse-to-patient ratios. According to a study published in the New England Journal of Medicine, American patients generally express a higher satisfaction with their hospital stays when cared for and treated in facilities with a higher ratio of nurses to patients. They rated their experience with their hospital stays more positively than patients admitted to hospitals with poor staffing and higher nurse workloads. A recently published study in Health Services Research (2010) titled "Implications of the California Nurse Staffing Mandate for 22 N AT I O N A L N U R S E Other States," (Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H.L.), reveals that improving nurse-to-patient ratios has demonstrated significant positive outcomes: ■ New Jersey hospitals would have 14 percent fewer patient deaths and Pennsylvania 11 percent fewer deaths if they matched California's 1:5 ratios in surgical units. ■ California RNs have far more time to spend with patients, and more of their hospitals have enough RNs on staff to provide quality patient care. ■ Fewer California RNs miss changes in patient conditions because of their workload than New Jersey or Pennsylvania RNs. ■ In California hospitals with better compliance with the ratios, RNs cite fewer complaints from patients and families and the nurses have more confidence that patients can manage their own care after discharge.  ■ California RNs are far more likely to stay at the bedside, and less likely to report burnout than nurses in New Jersey or Pennsylvania. There is a direct correlation between nurse satisfaction and patient satisfaction reported in the scientific, peer-reviewed literature, a study titled, "Nurse Burnout and Patient Satisfaction", Vahey, D.C., Aiken, L.H., Sloane, D.M., Clarke, S.P., & Vargas, D. (2004), published in the journal, Medical Care. The authors reported the following: Results of the survey showed: Patients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout. The overall level of nurse burnout on hospital units also affected patient satisfaction. Conclusions of the survey were: Improvements in nurses' work environments in hospitals have the potential to simultaneously reduce nurses' high levels of job burnout and risk of turnover, and increase patients' satisfaction with their care. More recently, in a 2008 article published in the New England Journal of Medicine titled, "Patients' Perception of Hospital Care in the United States," authors Jha, Orav, Zhen, and Epstein reported the following: Results: As compared with hospitals in the bottom quartile of the ratio of nurses to patient-days, those in the top-quartile had a somewhat better performance on the HCAHPS survey (e.g., 65 percent versus 70.2 percent of patients responded that they "would definitely recommend" the hospital; P<0.001). For example, those in the top quartile of HCAHPS rating performed better than those in the bottom quartile with respect to the care that patients received for acute myocardial infarction (actions taken to provide appropriate care as a proportion of all opportunities for providing such actions) and for pneumonia in unadjusted analysis. Conclusions: This portrait of patients' experiences in U.S. hospitals offers insights into areas that need improvement, suggests that the same characteristics of hospitals that lead to high nurse-staffing levels may be associated with better experiences for patients, and offers evidence that hospitals can provide both a high quality of clinical care and a good experience for the patient. Investigators have linked the HCAHPS data to the American W W W. N A T I O N A L N U R S E S U N I T E D . O R G NOVEMBER 2010

• Cover