Background
There is increasing recognition that traditional indicators of clinical outcomes such as mortality and complication rates are inadequate surrogate measures for good care, and that a more holistic approach is needed [
1]. In addition to its intrinsic ethical value, good patient experience has been consistently positively associated with patient safety and clinical effectiveness across a wide range of disease areas, study design settings, population groups and outcome measures [
2]. Both the 2008 report “High Quality Care For All” [
3] and the 2010 White Paper "Equity and excellence: liberating the NHS" [
4] have enshrined good patient experience as a cornerstone of good clinical care and a central goal for the NHS.
In response to this, Patient Reported Experience Measures (PREMs) have been developed to quantify patient experience in order to inform broader quality improvement strategies [
5]. However, the focus of PREM research conducted to date has either been generic or focused on chronic medical conditions. Questionnaires have been developed for general adult inpatients [
6], general practice [
7], children’s services [
8], mental health [
9] and maternity services [
10] within the NHS. Condition specific tools have been developed for cancer [
11], diabetes [
12], coronary heart disease [
13] and stroke [
14]. Very little research has been done looking specifically at experiences of patients undergoing emergency surgery.
Emergency surgery can be a particularity challenging area for patient experience. Patients present acutely unwell, in pain and distressed. Admission by definition is unplanned and frequently occurs at night. The patient journey within the hospital can be complicated, with numerous transfers between clinical areas and teams making continuity of care challenging. In comparison with elective patients, care is often co-ordinated by more junior members of staff and patients may not have access to additional avenues of support such as specialist nurses.
The aim of this study was to explore the relationship between patient experience and overall satisfaction for patients undergoing emergency intra-abdominal surgery.
Discussion
Improving patient experience is a valid endeavour in itself, and numerous studies have demonstrated an association between patient experience and improved clinical outcomes, patient safety and reduced healthcare costs [
20]. That said, patient experience is a subjective and multi-factorial phenomenon, and literature concerning patient experience can be nebulous and imprecise. This study identifies two dominant themes central to good patient experience: good information provision and a pleasant and caring ward environment are consistently associated with higher overall patient satisfaction. It is too easy to say that this is obvious, yet there are many aspects of the patient pathway examined in this study that are not strongly associated with satisfaction.
The results demonstrate that patients who felt well informed about their condition and their treatment, and had received good explanations, both pre and post-operatively, reported higher levels of satisfaction with their overall experience. There is a strong body of evidence supporting information as a determinant of good patient experience in a wide variety of clinical settings, including acute care [
21]. The clinical team are a prime source of patient information during the admission, and ensuring enough time to explain and discuss the diagnosis and treatment options with each patient has been identified as a key component of good clinical care [
22]. It has been recognised that patients’ information requirements change during the course of an illness [
23], and the realities of a busy surgical take may mean that clinical team alone may struggle to meet patients’ information requirements at all stages during their admission.
Different methods of providing information could compliment the oral information given by the clinical team. Traditional methods such as written patient information leaflets explaining the condition and treatment options and covering frequently asked questions about post-operative recovery [
24] remain a simple and easy way of providing patients with supplementary information. Furthermore, the digital era has transformed the way that some patients access health information, and there has been a rapid growth in the websites and apps available to inform, educate and empower patients [
25]. However, a “Digital Divide” has been recognised between the ability of different age and socioeconomic groups to access electronic resources, with the patients who stand to benefit the most from information provision the least able to access it electronically [
26]. Care needs to be taken when introducing electronic resources to ensure that they do not perpetuate health inequalities, and that the information requirements of those who lack Internet access are met through other methods.
It has long been recognised that night-time noise has a deleterious effect on patient experience [
27]. It is interesting to note that although patients reported experiencing night-time noise from other patients, only night-time noise from staff had a significant effect on overall patient satisfaction. Even though there must be a significant overlap in the noise from fellow patients and the noise from staff overnight, patients seem to make a distinction between the two when asked to evaluate their overall experience. This suggest that patients are willing to tolerate some aspects of a hospital admission such as noise from a distressed patient at night without it having a significant impact on their overall satisfaction, whereas other aspects, such as noise from staff, colours their perception of the entire experience. Furthermore, night-time noise highlights the dilemma around what is realistically modifiable in a hospital setting, and how to manage conflicting priorities between doing things that improve the patient experience for an individual patient (such as ensuring a quiet ward at night) with other clinical considerations (such as delivering safe care 24 h a day on a busy acute ward). The nature a busy general surgery ward makes it very difficult to completely eliminate night-time noise, however the result suggest that taking measures to reduce the noise created by staff working at night could significantly improve the overall patient experience.
The strengths of using a questionnaire-based survey to study patient experience lies in that it utilizes a validated tool that can be relatively quickly and cheaply administered to large numbers of people, generating generalizable and easily analysed data that can be tracked over time and compared with other centres [
28]. However, relying on questionnaires alone may result in the collection of only superficial data, with depth and nuance lost in attempting to reduce the complexity and diversity of experiences encompassed in one patient episode into simple, closed generalizable questions [
29]. To further elucidate beliefs on what constitutes a “good patient experience” would require qualitative research methods such as focus groups and semi-structured interviews to inductively explore patient expectations of their hospital stay.
At 78%, the response rate for this study is high: a typical response rate of between 63 and 69% is quoted in the literature describing the development of this questionnaire [
30]. It is also considerably higher than the average 60% response rate for medical mail surveys [
31]. Despite this, this study is limited by the fact it has a relatively small sample size. Undeniably, a degree of selection bias was introduced by the time limitation on following up patients after discharge, which meant that older, sicker patients with protracted inpatient stays were under represented (Fig.
1). Studies have suggested that older patients tend to report higher patient satisfaction scores [
32,
33], however, longer hospital stays have been associated with lower patient satisfaction [
34], therefore it is difficult to assess the likely impact of this on the data.
Traditional methods of evaluating clinical outcomes, such as complication rates, length of stay and 30-day mortality, have an important role in evaluating outcomes, but it is crucial to recognise their limitations. Traditional methods are limited in the scope of what they measure and what is consider to be a "poor outcome'. Lack of morbidity and mortality is not an adequate surrogate measure for good care. A patient may have technically perfect surgery, a prompt discharge and suffer no complications but spend their time in hospital frightened and anxious, being cared for on a dirty, noisy ward by an indifferent clinical team without any explanation or involvement in the decisions around their care. Arguably that patient has received poor care, but would have had a "good” outcome according to traditional measures. Using patient experience as an outcome measure allows for a more holistic and patient-centred evaluation of service delivery, and highlights ways of improving care in a way that matters to patients. Patient experience measures have been shown to be robust, distinctive indicators of healthcare quality [
35], and have been successfully used to drive local improvement strategies across a number of healthcare settings within the NHS [
36].