This special issue of The Journal of Ambulatory Care Management is devoted to issues of consumerism and patient satisfaction in ambulatory care. Over the past decade, there has been a shift in health care delivery from acute to ambulatory care settings (Kaldenberg, Mylod, & Drain, 2002), largely due to cost-control initiatives in the hospital sector. New drugs and technologies, increased access to information, and the growth in complementary and alternative medicine also have contributed to the new health care environment (Vinn, 2000). Although the consumerization of health care often has been overstated, one prediction is clear: Patients will assume an even greater share of their health care costs and become more active consumers of health care (Morrison, 2000). As consumers pay more out of pocket, they will demand better service, prompting payers to increase their profiling efforts (Drain, 2001).
The goal of this special issue is to highlight the use of patient perceptions and satisfaction as measures of service quality and improvement in ambulatory care. According to the Kaiser Family Foundation and the Agency for Health Care Research and Quality (2000), service quality continues to play a disproportionate role in patients' utilization of health care. Although patients have different expectations and perceptions of service quality, patient evaluations of service and care correlate well with objective measures of health care quality: "Patient satisfaction is important because it is a component of care as well as an outcome of care" (Press, 2002, xi). As illustrated in Figure 1, patient satisfaction has many direct and indirect benefits. Service is important for differentiating providers and for attracting new patients. More important, however, is the long-term impact of patient satisfaction. Quality service creates lasting impressions that increase the retention of current patients and build partnerships between patients and providers that improve outcomes.
In the years ahead, it will be increasingly important for ambulatory care organizations to measure patient experiences for quality and service improvement. Facilities typically survey patients to collect information about their health care services and providers. Patients may be asked (a) to report what happened by selecting from among a number of fixed choices or (b) to rate, or evaluate, service along a scale from "very poor" to "very good." Today, the term patient satisfaction often is applied to any patient rating, whether patients are rating their satisfaction or "highly specific, clinically important elements of care" (Cleary et al., 1993, 32). According to Ware and colleagues, "patient satisfaction ratings are distinct from reports about providers and care. Reports are intentionally more factual and objective. Satisfaction ratings are intentionally more subjective; they attempt to capture a personal evaluation of care that cannot be known by observing care directly" (1983, 247).
Although it is tempting to try to obtain objective markers of quality by asking patients to report their experiences, patient reports are not free of patient perceptions and subjectivity. Both reports and ratings consist of cognitive evaluations and emotional reactions to the structures, processes, and outcomes of service. Indeed, the cognitive processes involved in factual judgments (patient reports) and in attitudes (patient ratings) share more similarities than differences (Tourangeau, Rips, & Rasinski, 2000). Patients' expectations and judgments of appropriateness, for example, may influence reports of how long they waited to be seen by their doctors (see Leddy, Kaldenberg, and Becker in this issue for additional discussion).
If improved service and patient satisfaction are goals, organizations must meet patient standards. To address the continued rise in consumer-driven health care, providers need to listen to their customers-their patients-and continually improve to meet or exceed their expectations. Patient reports provide limited information for quality improvement and are more appropriate for quality assessment and accountability. "Although accountability measures may identify areas and organizations that need improvement, these results are necessarily so far downstream that they are rarely of much help to the process of improving the delivery of health care" (Solberg, Mosser, & McDonald, 1997, 136). The quality movement in U.S. health care can be guided only so far by report cards (Press, 1997, 2002). Patient ratings-and patient satisfaction-must become an integral part of all quality improvement programs.
In the first article of this special issue, Lloyd describes how to improve ambulatory care by listening to patients and utilizing different approaches to gathering customer input and measuring quality, including patient satisfaction. By listening to the voice of the customer before, during, and after patients' episodes of care and combining these patient evaluations with the voice of the process, providers can design customer-friendly systems and identify opportunities for improvements.
Listening to the voice of the customer, Clark presents the results from one of the largest national studies of patient satisfaction ever conducted among medical practice patients. Across all the issues surveyed, providers' sensitivity to patient needs was most highly associated with evaluations of care and service. Clark explains these results in terms of patient roles and the need for providers to acknowledge patients' explanatory models. Clark demonstrates how patient ratings and evaluations can be successfully integrated into quality-improvement programs by translating his findings into clear, actionable practices for improvement.
In her article, Cariello discusses an innovative approach for increasing service quality and patient satisfaction in primary care settings-while lowering costs. Computerized telephone nurse triage (CTNT) allows patients to speak directly to registered nurses by telephone to obtain information and recommendations for appropriate treatment. Cariello found that callers, particularly working mothers, rated the quality of their CTNT experiences very highly. Coupled with the cost savings, CTNT may prove to be a particularly attractive alternative to traditional models of health care delivery, benefiting both providers and consumers as well as providing new primary health-care access points for underserved populations.
Leddy, Kaldenberg, and Becker investigate one of the Institute of Medicine's six aims for improving health care-timeliness-and one of patients' most common complaints-wait times. Leddy and her colleagues find that perceived quality of time, rather than quantity, is critical to patients' experiences. For example, patient satisfaction more than doubled for patients with the longest waits when waiting rooms were perceived as comfortable and pleasant. In addition, complex organizational structures (e.g., facilities in teaching organizations, medical schools, or foundation settings) were associated with longer waits than facilities in simpler (e.g., freestanding, independent, or nonteaching) organizational structures. Leddy et al. conclude that "[a]lthough the waiting room is not the only area where improvements can be made, it is certainly one where mediocrity will be less tolerated as time goes on."
Oermann provides specific suggestions on how to improve patient satisfaction while patients wait. Previous research has shown that if patients are occupied during their wait, their satisfaction with the visit tends to increase. Oermann found that educational intervention combined with nurse interaction was associated with increased patient satisfaction with the health education received but not with overall satisfaction with the visit. These results suggest that providing health education while patients wait is a viable quality-improvement tool, but it may not supplant environmental factors.
Rave and his colleagues provide an excellent case study of quality improvement and improved patient satisfaction within the outpatient setting of Northwestern Memorial Hospital (NMH), one of the country's leading academic medical centers. Rave et al. discuss NMH's Best Patient Experience Project and how others may implement it. NMH increased patient satisfaction by listening to patients and responding to their needs while never losing sight of the importance of employee satisfaction.
Williams, O'Connor, and Shewchuk conclude this special issue with their study of variables related to health maintenance organization (HMO) membership and members' likelihood to recommend HMOs. Previous research has shown that physician panel size is associated with health plan satisfaction. However, information regarding the composition of these panels (i.e., the ratio of primary care physicians to specialists) is unknown. The authors suggest that choice among primary care physicians and satisfaction with primary care physicians are more important for member satisfaction with the health plan than members' recommendations of hospitals and specialists.
In sum, consumer-driven health care is no longer a prediction; it is reality. Although patients have access to an increasing array of health care information, service quality continues to play a significant-and often decisive-role in patients' utilization of ambulatory care services. I previously have stated that, with the rise in consumerism, primary care would be at the forefront when patient satisfaction emerged as a key indicator of quality (Drain, 2001). It is now clear this statement should be extended to include all of ambulatory care.
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