1. A PATIENT SATISFACTION SURVEY OF
THE MASSACHUSETTS GENERAL HOSPITAL CANCER CENTER
A Capstone Seminar Paper for
HSA 596 Seminar in Health Services Administration
Presented to Dr. Robert Guerrin
Department of Health Service
Administration
Russell Sage College
In Partial Fulfillment of
the Requirements for the Degree of
Master of Science in Health Services Administration
by
Mark A. Campoli
May 1995

2. TABLE OF CONTENTS
I. PROBLEM STATEMENT................................................3
II. LITERATURE REVIEW..................................................5
III. METHOD.......................................................................14
IV. RESULTS.......................................................................18
V. DISCUSSION.................................................................31
VI. REFERENCES................................................................34
VII. APPENDIX.....................................................................37
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3. PROBLEM STATEMENT
Quality of patient care has become a central topic as the nation and the health care
industry reevaluate the service delivery system. It has become increasingly clear that the
health care system has evolved into an unwieldy and expensive entity. All aspects of health
care are being examined in an attempt to develop a more efficient and effective delivery
system. Due to survival concerns of hospitals and health care plans in this time of
upheaval, more emphasis is being placed on patient-centered care as a means of directly
addressing treatment efficiency and efficacy. Implementing patient centered care means:
• assessing patient perceptions of the organization and of the
coordination of their care;
• respect for their values, preferences, and needs;
• the provision of information about their illness and treatment
procedures and how their lives will be affected;
• the addressing of physical comfort, emotional support, and involvement
of significant others;
• and the quality of the interpersonal aspects of their care.
Patient satisfaction is one component of the measurement of the patient-centered view of
quality of care. This study will focus on the assessment of patients' overall satisfaction and
satisfaction with the interpersonal aspects of their care. A recent survey published in
Health Communication found that patients placed a high value on interpersonal
communication and relationships where concern was demonstrated were highly regarded.
From the patient's perspective, the interpersonal treatment forms a more lasting impression
of the healthcare agency than do the clinical and technical aspects of care (Ruben, 1993).
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4. The Cancer Center at the Massachusetts General Hospital (MGH) is a
comprehensive and multifaceted cancer treatment center providing services of assessment,
diagnosis, education, support, treatment and follow-up. An interim evaluation of service
delivery at the Center was recently completed by the MGH Cancer Center Patient Focus
Team. The team's mission is to develop a system of care for cancer patients and their
families that is specifically focused on and responsive to patients' needs. All aspects of care
are to be designed "through the eyes, ears, thoughts and emotion of the patient" (Cancer
Center Patient Focus Team Interim Report, 1994). As a result of this mission, the
evaluation was based on patient focus group results and covered a range of topics
including accessibility, patient and family support, coordination of care, education,
environment, and interpersonal aspects. The report recommended several clinical and non-
clinical initiatives. These initiatives are seen as essential to uphold MGH's world class
quality during times of unprecedented turbulence in health care. One of the initiatives from
the Patient Focus Team Interim Report is to maintain and communicate the patients'
perspective by periodically soliciting patient feedback. This study attempts to evaluate this
initiative by examining one MGH clinical cancer service and assess patient satisfaction
directly from patient reports. The results will be used to determine existing strengths and
to generate recommendations for improvement. It is also hoped this study may serve as a
model for further evaluation of the delivery of care in a specific and useful manner. In
addition to describing patient satisfaction with the interpersonal aspects of the service
delivered by the clinic in question, demographic variables will be examined to help assess
the extent to which variations in the reported quality of care might be attributed to certain
patient characteristics.
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5. LITERATURE REVIEW
Background of the Problem
Quality of care and patient satisfaction.
In the 1970's, the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) defined quality as "the degree of adherence to generally recognized
contemporary standards of good practice and achievement of anticipated outcomes for a
particular service, procedure, diagnosis or clinical problem" (Appel, 1991). This
description of quality speaks to the need for standards and measures but does not include
the concept of using input from the recipient of care. To many health care professionals,
the most visible result of the commission's agenda for change has been the inspection and
testing of clinical indicators as measures of the quality of medical care. Although clinical
treatment measurements are important, there are other activities underway that are likely
to have a far more reaching impact for health care providers (Appel, 1991). The JCAHO
is using the mechanism of standards revision to lead healthcare organizations into a
transition to Continuous Quality Improvement (CQI). The new set of leadership standards
has appeared in the Accreditation Manual for Hospitals (AMH: JCAHO, 1994). The
AMH articulates an application of W. Edwards Demings 14-point program for Continuous
Quality Improvement as it relates to health care. Demings is best known for having helped
Japanese industry rebuild its economy after World War II. However, he is relatively
unknown in American industry and practically unknown to the U.S. health care
environment (Neuhauser, 1990). The special application of Demings' points compiled by
the JCAHO identify quality as a survival issue. The commitment to CQI translates into
better service for the patient and the community. It further states that healthcare should
cease dependence on inspection to achieve quality. Rather, the focus should be
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6. shifting from quality by inspection to quality by consumer or patient satisfaction (Michigan
Hospitals, 1991).
In striving to arrive at a more functional description of quality using CQI concepts,
the Task Force for Quality Management for Health Care Delivery states that quality may
be described within the following context: " a healthcare delivery system is a series of
interlinked processes, each of which results in one or more outputs. Quality represents an
individual's subjective evaluation of an output and the personal interactions that take place
as the output is delivered to the individual" (QMMP, 1989).
The Health Security Act of 1993 was created to set standards and guidelines for
health professionals, reorient quality assurance programs to measure outcomes rather than
to blindly promulgate regulations, increase the national commitment to medical research,
and promote primary and preventative care. The Health Security Act guarantees that the
pursuit of six fundamental principles will be emphasized and that they are not negotiable.
These principles include the guarantee of benefits to all, cost containment, enhancement of
quality, access to care, reduction of paperwork, and increase in responsibility for
individual health. The third of these principles is the enhancement of quality of care: to
make the world's best care better. The purpose of this principle is to protect and enhance
of the quality of patient care. Within the principle of enhancing quality, one of the eight
clearly stated objectives for implementation requires that regular surveys of consumer
satisfaction be used to measure health plans. Consumers will receive "quality report cards"
that request information on the performance of health care plans and patient satisfaction.
These report cards will hold plans accountable for meeting high standards. The National
Quality Program will help states share information on health plan performance as they
revamp their health care delivery systems (The White House, 1993).
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7. In addition to being of primary interest to regulators, patient satisfaction is of great
interest to health care researchers. Patient satisfaction is widely used as a dependent
variable to evaluate medical care and has been identified by the National Center for Health
Services Research and Health Care Technology Assessment as one of the three major
categories of criteria for evaluation of health care systems (Lewis, Scott, Pantell, & Wolf,
1986). The rationale for making subjective assessments of patient care part of quality
assurance was articulated by Donabedian (1980), who identified patient satisfaction as a
factor directly influencing compliance with medical regimens and decisions regarding
continuity and access to care. Increasingly, proper evaluation of patient satisfaction is of
primary importance to health care providers, insurers, and patients. Hospitals need to
examine the way they collect data and the type of satisfaction data gathered. Patient
satisfaction survey instruments must provide specific information on what patients need,
not only general ratings of satisfaction. David Gustafson, PhD, from the University of
Wisconsin Hospitals states, "The typical patient satisfaction survey that simply asks, 'How
do you like our doctors, nurses, our cafeteria food,' doesn't get at customer needs at all"
(Koska, 1992). Specific criteria about the relationship of need and the type of service
provided, must be established. This must then be followed by baseline monitoring of how
well needs are being met. Improvements can be charted that meet the goals of quality
assurance or CQI (Koska, 1992).
The demand for quality care is not only coming from regulators, but also from
purchasers of managed care and patients. Quality will no longer be assumed present
merely because of a written report or charted record of outcome. Purchasers and
consumers alike are demanding high value for dollars spent (Edford, 1990). Patient-
consumers are demanding more information on health costs, utilization patterns, and
outcomes. There is growing consensus that monitoring quality of care should be based, at
least in part, on patients' perceptions (Boscarino, 1992).
Hospitals are responding to this initiative by implementing patient-focused work
redesign strategies. These efforts have resulted in downsizing in an attempt to produce
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8. flatter organizational structures, fewer levels of hierarchy or specialization, and improved
customer service. Rapid development of this trend has focused on three essential criteria
for meeting current demands of the healthcare marketplace. Institutional success will
depend on patient satisfaction, patient outcomes, and cost reduction.
Providers of patient care services must meet and exceed their patient-customers'
expectations as this is rapidly becoming a top agenda for today and the future. The price
health care providers and institutions pay for dissatisfied customers will be high. Whiteley
(1991) reported that almost 80% of the identifiable reasons why customers switched to
competitors' products had nothing to do with the product itself. The breakdown of
customers' reasons for switching is as follows: 45 percent switched because service was
rude and unhelpful, 20% cited a lack of personal attention, and only 15% switched
because of lower cost (Whiteley, 1991). The implications of this study present powerful
incentives to health care providers. If product quality is equated with technical expertise in
healthcare then the most technically advanced hospital in the world would only satisfy
20% of its customers if the evaluation were based on technical expertise alone. Clearly,
technical know-how is not enough.
The new patient-focused model crosses traditional departmental lines. In this
model, the patient is the center of activity. A patient-focused center takes health care
professionals off the assembly line and puts them to work on teams, empowering them to
build a quality product. In a patient focused team, staff people receive sufficient cross
training so they can treat patients with a similar diagnosis from admission to discharge.
The patient-focused unit becomes a mini-hospital designed to bring services closer to the
patient's bedside. This replaces the necessity that the patient struggle with traditional
hospital operations which have become a maze of inefficiency and an endless line of
nameless faces. At one hospital the goal of the first of its focused-care centers is to meet
more than 80% of all patient needs with staff and equipment delivered right to the patient
unit (Troup, 1992).
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9. Interpersonal Aspects of Treatment
In his classic text, Explorations in Quality Assessment and Monitoring, Avedis
Donabedian, M.D. (1980), has written that there are two primary components to a health
care practitioner's performance: technical quality and management of the interpersonal
relationship. Technical care is measured by comparing it to standards of care and expected
outcomes as established by the scientific literature and supplemented by expert opinion.
Physicians and nurses evaluate the content quality of the technical care. Interpersonal care
is assessed directly, in an analogous fashion, by comparing the way it is conducted to
"standards" which, are primarily evaluated by and based upon the expectations of patients
and their families. The interpersonal process can also be assessed by its "specific" outcome
which, in this case, is patient satisfaction. The delivery quality is associated with the
interpersonal relationships on which the delivery of any service is based. The interpersonal
process is important because patients and practitioners value certain aspects as desirable.
It is also believed that certain management styles are more conducive to patients'
participation in care. The interpersonal aspect of care is often overlooked, the technical
side being viewed as of primary importance. However, the interpersonal process is the
vehicle for technical care in almost all cases.
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10. According to Donabedian, the practice of medicine is a process that results in an
output. However, it is not the output alone. The quality of an output is arrived at from the
customers point of view, the measure is determined via an evaluation. It is formed from
the individual's perceptions of the output and is rooted within the individual's frame of
reference (Donabedian, 1980).
A recent survey (Ruben, 1993) found that patients placed a high priority on
personal concern, interpersonal communication and relationships. From the patients'
perspectives, the interpersonal treatment they receive forms a more lasting impression of
the healthcare agency than do the clinical and technical aspects of care.
The Measurement of Satisfaction
One patient survey that uses an assessment of needs approach is the
Picker/Commonwealth Patient-Centered Care survey. This survey instrument is designed
to elicit reports from patients about concrete aspects of their experience in lieu of the
ratings of satisfaction generally used on patient surveys. One aspect of the survey that
distinguishes it from other patient satisfaction surveys is that it focuses on eliciting reports
about highly specific, clinically important elements of care. Patient reports about discrete
events provide information very different from general evaluations. Responses to
questions about satisfaction usually depend on both an evaluation and an emotional
reaction. Reports on the other hand, reflect patients perceptions of what actually occurred.
Reports are less likely than
ratings to be influenced by expectations, personal relationships, gratitude, or response
tendencies related to gender, class, or ethnicity (Cleary, Edgman-Levitan, Walker, Gerteis,
& Delbanco, 1993).
The Picker/Commonwealth Survey was administered to 6,455 patients in 62
hospitals. The results from this study have been used to make recommendations regarding
coordination of care at the bedside, coordinating clinical support and ancillary services
(Gerteis, 1994), identifying gaps in service due to age and severity of illness bias (Cleary,
Edgman-Levitan, McMullen, & Delbanco, 1992), and utilization of patient generated
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11. information in the improvement of quality of care (Cleary, Edgman-Levitan, Roberts,
Moloney, McMullen, Walker, & Delbanco, 1991).
Cleary et al. (1992) explored various factors that were hypothesized to influence
patients' level of satisfaction with their hospital care such as patient demographics (age,
sex, education, income), patient health status, patient preferences for being more or less
informed and involved in their own care, and patient reports on problems that relate to
specific processes of care (e.g., physical care, emotional support, pain management).
Although these factors were significant, they did not account for the total variance in
satisfaction reports. The actual care given still accounted for the largest proportion of the
variance in the satisfaction rating. These authors, utilizing the Picker/Commonwealth
Inpatient Survey, found that there were correlations between patient satisfaction and
health status, age, and sex. The strongest predictor was health status with healthier
patients giving better evaluations of their treatment. Women tended to be more satisfied
with their care than did men, and older patients were more satisfied than younger patients.
Patients who preferred more involvement in their treatment and low income patients
tended to give worse evaluations of their care. The original study used a patient
assessment of health status and the authors recommend that it would be useful to have an
independent assessment of health status in future studies (Cleary et al., 1991).
Breast Cancer Treatment
Cancer is a major health problem in this country. Although mortality rates for
other diseases such as heart disease, stroke, and other conditions have been decreasing,
deaths due to cancer have been on the rise, accounting for 23% of all deaths in the United
States. There have also been increases of indicated cases in the major sites of the disease,
which includes lung, prostate, and breast cancer. For women, breast cancer accounts for
32% of all new cases. During this decade alone, more than 1.5 million women will be
diagnosed and 30% of these women will die from the disease. The incidence of breast
cancer continues to rise despite major clinical studies which include trials of dramatic
treatments such as bone marrow transplantation. Increasing numbers of women undergo
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12. difficult therapies, and somehow cope with 5-year relative survival rates of 53% for White
Americans and 38% for Black Americans (American Cancer Society, 1993).
Treatment for breast cancer may include surgery, radiation, and chemotherapy or
combinations of these. Surgical mastectomy or lumpectomy require physiologic recovery,
and exercise is needed to restore the range of motion to the affected arm. Side effects of
chemotherapy or radiation may include nausea and vomiting, hair loss, fatigue, anorexia,
skin reactions, and pulmonary effects. Emotional responses to surgery, radiation, and
chemotherapy for breast cancer may include depression, generalized anxiety, death
anxiety, confusion, and a preoccupation with health (Andersen, Anderson, & DeProsse,
1989).
Much of the psychological research in cancer rehabilitation has been focused on
preventing or reducing psychological and behavioral burdens associated with treatment
and towards improving the quality of life. Several studies have documented that quality of
life benefits, such as reduced emotional distress, enhanced social adjustment, pain
reduction, and so forth, accrue from a psychosocial intervention offered to cancer patients.
These studies clarify the importance of psychological and behavioral factors for cancer
patients and the routes by which such factors may have important health consequences
(Andersen, Kiecolt-Glaser, & Glaser, 1994).
The well publicized study of Spiegel, Bloom, Kraemer, & Gottheil (1989) reports
the positive effects of weekly supportive group therapy on survival time in patients with
metastasized breast cancer. The authors reported that advanced breast cancer patients
who participated in professionally guided support groups lived, on the average, twice as
long as members of a control group who did not attend support groups. The group
therapy seemed to have extended women's lives by an amount that Spiegel et al. (1989)
considered to be both statistically and clinically significant. Further signs of progress in the
area of previously neglected factors of interpersonal and social support emerge through
the work of Blanchard, La Brecque, Ruckdeschel, & Blanchard (1990). These
investigators have developed techniques for studying the doctor-patient relationship within
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13. the milieu of hospital rounds as well as the effects of medical staff behaviors in relation to
specialty units (Blanchard et al., 1990). It is felt the fears and uncertainty with treatment
outcomes increase the need for interpersonal support and reassurance, and that from the
patients' point of view, the most painful issue of all, is the emotional and social adjustment
to living as a cancer survivor.
Rationale for the Study
It is apparent that treatment for cancer is demanding and drains a patient's physical
and psychological resources. The interpersonal aspects of care and the support provided
during treatment appear to have significant benefit in quality of life and emotional
adjustment. In light of this significance, the overall priority of patient satisfaction in
assessing quality of care, and the priority of the MGH Cancer Center Patient Focus Team,
this study attempted to evaluate the overall satisfaction and the interpersonal satisfaction
with care delivered by the MGH Comprehensive Breast Health Center. Demographics,
particularly type of treatment, were examined to determine if they influenced the
satisfaction ratings.
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