- Open Access
Primer on adult patient satisfaction in perioperative settings
Perioperative Medicine volume 8, Article number: 11 (2019)
The topic of patient satisfaction has gained increasing importance over the past decade. Due to the impact of patient satisfaction on health care quality, understanding factors that predict satisfaction is vital. The purpose of this review is to examine the literature and identify factors related to patient perioperative satisfaction as well as predictive variables that, if modified, can enhance satisfaction scores of patients undergoing surgery. Our review reports that patient satisfaction scores are affected by modifiable factors such as clinician-patient communication, information provision to patients, and operational function of a hospital. Non-modifiable factors affecting patient satisfaction scores include patient demographics such as gender, age, and education. In order to enhance patient perioperative satisfaction, we suggest that anesthesiologists and surgeons focus their efforts on enhancing their communication skills and providing information that is appropriately tailored to the understanding of their patients.
In 2016, the United States (U.S.) spent nearly 18% of its gross domestic product (GDP) on healthcare whereas the next highest comparable country (Switzerland) devoted less than 13% to this category (OCED, 2018). Within that context, the U.S. also ranks as one of the worst in health care parameters such as infant mortality and prevalence of chronic diseases (Squires & Anderson, 2015). The high U.S. health care system GDP, which has been fueled for decades by increased operational costs, is mostly without corresponding improvement in clinical outcomes (Obama, 2016). In an effort to improve health care outcomes and decrease cost, the U.S. government has adopted a series of measures that are based partially on the Triple Aim proposed by Don Berwick: (1) improve patient experience, (2) improve population health, and (3) reduce per capita healthcare costs (Berwick et al., 2008).
Based on the work of Berwick and others, in 2013, the Centers for Medicare and Medicaid Services (CMS) initiated the hospital Value-Based Purchasing (VBP) program that altered hospital reimbursement from procedure-based to hospital performance data. This novel approach has challenged medical institutions to deliver high-quality care and reduce costs (Haley et al., 2016). As of 2018, there are four equally scored domains of a hospital’s VBP score: safety, clinical care, cost reduction, and patient experience. Because 25% of a hospital’s VBP score for 2018 is measured by patient experience, hospitals have been increasingly investing in strategies to improve patient-related experience and satisfaction (Kain et al., 2014; Dalal et al., 2016). Accordingly, this growing focus towards evaluating patient experience outcomes should prompt health care institutions to explore critical factors that may advance overall health outcomes and care.
We submit that because healthcare organizations are increasingly emphasizing patient satisfaction, it is imperative that anesthesiologists and surgeons be educated on the concept of patient experience within the context of the perioperative environment. The purpose of this report, therefore, is not to merely review the topic of perioperative patient satisfaction, but rather focus on the identification of several variables that have been identified in the literature as predictors of satisfaction scores (Fig. 1). Indeed, while many anesthesiologists and surgeons believe that patient satisfaction with their perioperative experience is a function of technical variables such as surgical and anesthetic techniques, in reality, patients do not have access to such information and as such rely solely on surrogate variables such as communication skills and empathy of perioperative clinicians.
Hospital patient satisfaction measurement: a brief history
In 1995, the Center for Medicare and Medicaid Services (CMS) partnered with the Agency for Healthcare Research and Quality (AHRQ) to develop the Consumer Assessment of Health Providers and Systems (CAHPS) surveys in response to the lack of available information regarding consumers’ experiences of their health care and services (CMS. Center of Medicare and Medicaid Services, 2018; Goldstein et al., 2005). The goals of the CAHPS surveys are to (1) develop standardized surveys that organizations can use to collect comparable information on patients’ experience of care and (2) generate tools and resources to support the dissemination and use of survey results to inform the public and improve health care quality (CMS. Center of Medicare and Medicaid Services, 2018; Agency for Healthcare Research & Quality, 2018). The hospital-specific survey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), was implemented nationally in 2006 and includes questions on communication with nurses and doctors, the response of hospital staff, hospital environment, communication about medicines, discharge information, overall hospital rating, and patient demographics.
The first public reporting of HCAHPS data was available in 2008 and included 4032 hospitals. A New England Journal of Medicine study using these data showed that on average, 63% of patients rated their care greater than 9 out of 10, 26% gave a rating between 7–8, and only 11% gave a rating less than 6 (Jha et al., 2008). Since the first public reporting, patient satisfaction scores have increased in all categories, although it is unclear if patients are more satisfied with their care or hospitals are better at managing the episode of care based on the HCAHPS questions (Mann et al., 2016).
Understanding patient satisfaction
Patient satisfaction is a subjective, complex, and multi-dimensional measure. It is defined as a health care recipient’s evaluation of the care they received and is affected by the recipient’s expectations and outcomes (Pascoe, 1983). Dissatisfaction occurs when discrepancies exist between a patient’s experience and their expectations. Given the multi-faceted nature of satisfaction including physical, emotional, social, and cultural components, it is no surprise that patient satisfaction is difficult to measure. While many validated patient satisfaction questionnaires have been published, the heterogeneity in their use makes it difficult to compare across multiple studies and in clinical practice (Caljouw et al., 2008; Sitzia, 1999; González et al., 2005; Chanthong et al., 2009). Thus, there is currently no “gold standard” to measure patient satisfaction. That being said, since CMS as well as commercial carriers formulate hospital reimbursement decisions based on the results of CAHPS surveys, special attention should be paid to these surveys although they may not be well validated scientifically.
Patient satisfaction and clinical outcomes
The relationship of patient satisfaction and clinical outcomes is frequently debated due to the difficulty in conducting randomized controlled trials to test this association. Specifically, because it is not ethically possible to prospectively assign patients to a “satisfied” and a “dissatisfied” group, all studies on this topic are cross-sectional or observational in nature and therefore reflect association rather than causation. The most significant factor, in our opinion, is the cross-sectional nature of the studies within this space.
In general, higher patient satisfaction has been associated with positive clinical outcomes (Doyle et al., 2013; Larson et al., 1996). In a recent extensive review article on patient experience and clinical safety and effectiveness, Doyle and colleagues showed that of the 55 cited peer review studies, 77% showed a positive association (high patient satisfaction was related to clinical safety and effectiveness), 22% showed no association and < 1% showed a negative association (Doyle et al., 2013). Patients who were more satisfied with their medical care showed greater adherence to treatment plans (Bartlett et al., 1984; Haskard Zolnierek & Dimatteo, 2009), fewer hospital readmissions (Boulding et al., 2011), and a greater intention to keep follow-up appointments (Freed et al., 1998). And patients treated at hospitals with higher patient satisfaction scores experienced lower rates of post-operative mortality, death after any complication, and minor complications (Sacks et al., 2015).
Moreover, some studies have shown no association between patient experience and clinical outcomes (Fisher et al., 2003; Sequist et al., 2008; Werner & Bradlow, 2006), whereas others have reported poorer patient outcomes with higher experience scores (Fenton et al., 2012). For example, Sequist and colleagues showed no significant associations between patient experience and clinical outcomes in a study of 373 practice sites and 119 primary care physicians (Sequist et al., 2008). Fenton and colleagues linked higher patient satisfaction scores to higher mortality rates even after adjusting for factors such as chronic disease, socio-demographics, and availability to care (Fenton et al., 2012). Furthermore, physicians’ attempts to satisfy patients can lead to negative clinical outcomes. For instance, to minimize post-operative pain, pain relief may be achieved by overprescribing opioids. These well-intended actions contribute to opioid addiction, death from opioid overdose, and ultimately our current opioid epidemic (Bernard et al., 2018).
The various relationships between patient satisfaction and clinical outcomes could be explained by the fact that patient experience and clinical outcomes are complex concepts that include multiple sub-domains, and a wide range of factors contribute to its assessment as well as study design and analysis.
Patient satisfaction and operational cost outcomes
The financial impact of patients’ satisfaction scores is an outcome that remains controversial although, as we indicated in the introduction, high patient satisfaction scores have direct and indirect financial benefits for hospitals. In a 2013 systematic review of 61 studies, 34% of articles reported a positive association (higher quality of care associated with a higher cost of care), 30% reported negative associations, and 36% reported no association (Hussey et al., 2013).
Under the CMS’s VBP program, hospitals are offered monetary incentives for higher HCAHPS scores. Tsai and colleagues found that patients who had surgery at hospitals rated higher in satisfaction (as measured by HCAHPS) cost less for Medicare than low-quality institutions (Tsai et al., 2016). Specifically, Medicare spent $2698 less on the average risk- and hospital-adjusted payment at 30 days for major surgeries such as coronary artery bypass grafting (CABG), pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, colectomy, or hip replacement. The most significant area in cost-reduction was on post-acute care and lower readmissions rates (Tsai & Orav, 2015).
Higher patient satisfaction has also been associated with reduced health care utilization by less frequent visits to the emergency room (Fenton et al., 2012). Indirectly, satisfied patients are more likely to refer family and friends to a hospital in which they have had a positive experience (Lee, 2008), producing more revenue. Conversely, some researchers have argued that there may be no or even negative effects of patient satisfaction scores on health care expenditures. For example, Fenton and colleagues reported that higher patient satisfaction was associated with higher inpatient utilization, greater total health care expenditures, and higher expenditures on prescription drugs (Fenton et al., 2012). The association of satisfied patient with the greater use of inpatient services and higher health care expenditures could be explained by increased likelihood that satisfied patients are more likely to seek health care. Overall, whether patient satisfaction scores contribute to health care expenditures is still up for debate.
Can we predict patient satisfaction hospital scores?
Although we can debate on whether or not patient satisfaction impacts clinical or hospital costs, it is clear that CMS will penalize hospitals based on the VBP program if their patient satisfaction scores are low. As a result, it is critical to identify the determinants of patient satisfaction and direct various interventions based on these predictors. In examining the literature, one can see that identifying determinants of patient satisfaction scores is highly complex partially because of the paucity of clinical outcome data that are connected directly to each provider (Fig. 1).
Modifiable factors: clinician communication skills
In the absence of such granular clinical data, patients tend to use proxies such as their providers’ communication skills when rating the quality of their medical care (Table 1). Specifically, patients place a high value on communication with healthcare providers within the perioperative settings (Hepner et al., 2004). For surgical patients, greater levels of detailed communication contribute to better patient satisfaction scores (Kahn et al., 2015). Patients highly value being treated with respect and knowing that providers are listening to what they have to say (Kahn et al., 2015). Satisfaction is also affected by the attention of staff to patient complaints (Gebremedhn & Lemma, 2017), prior explanation of diagnostic tests and procedures (Mira et al., 2009), and a surgeon’s effective communication pre-operatively and on the day of surgery (Tevis et al., 2015). The kindness and regard of caregivers in making patients feel safe improves patients’ perception of their surgical experiences (Capuzzo et al., 2007). Patients were dissatisfied with provider communication when they did not feel involved in the decision-making process and had poor continuity of care by the anesthesiologist (Heidegger et al., 2002).
Good physician communication has been linked to many positive clinical outcomes such as greater treatment adherence (Bartlett et al., 1984; Haskard Zolnierek & Dimatteo, 2009), improved health outcomes (Kelley et al., 2014; Stewart, 1995), and decreased risk of malpractice allegations (Hickson et al., 2002). Unfortunately, physicians may have a different perception of the care they provide when compared to the patient’s experience (Olson & Windish, 2010). Some reports have indicated that many physicians are rated low in their patient communication skills (Marvel et al., 1999; McBride et al., 1994). With the introduction of HCAHPS, improvements have been made in the provider and patient communication (Boissy et al., 2016); however, continued improvements in this area would be beneficial due to the significant impacts on patient experiences.
Information provision to patients
A major determinant of patient satisfaction across various inpatient and outpatient surgical specialties is information provided to patients (Table 2). There is a clear desire of information from patients (Caljouw et al., 2008; Mira et al., 2009; Lemos et al., 2009; Hawkins et al., 2012; Leinonen et al., 2001). Specific time points during the surgical experience in which information is provided are important and include the pre-operative visit, informed consent, surgical procedure episode, discharge, and postoperative care (Gebremedhn & Lemma, 2017; Mira et al., 2009; Fung & Cohen, 2001; Oswald et al., 2018). Patient satisfaction was higher when written information was supplemented with verbal information during the pre-operative visit (Johnson et al., 1999). In a cross-sectional study of 170 patients, more detailed information before surgery was found to increase patient anxiety (Forsberg et al., 2015). However, in randomized controlled trials of children undergoing surgery, more detailed pre-operative information was not found to increase child or parent anxiety (Kain et al., 1997; Inglis & Farnill, 1993). Patients dissatisfied with their surgical experience generally wanted more personalized information about the surgery, perioperative period, and home care instructions that is ideally provided in a format most appropriate to the patient educational level (Leinonen et al., 2001; Oswald et al., 2018; Forsberg et al., 2015; Otte, 1996).
Patient expectations and activation
Patient fulfillment of expectations is a predictor of satisfaction scores (Table 3) (Bjertnaes et al., 2012; Bleich et al., 2009). Consider a scenario in which two patients with the same diagnosis receive the same standard of care treatment, however one patient was anticipating an alternative treatment. Satisfaction scores of their health care encounters may differ. Additionally, patient activation can influence the patient experience. In this context, activation is described as being engaged and actively participating in one’s care. It involves a patient’s knowledge, skills, and willingness to manage their own health and care (Hibbard et al., 2004). An engaged patient is more likely to be more satisfied with the health care system as they may be more likely to ask questions to clarify their concerns or have a clear understanding of the reasons for their care. Greater activation can even improve health care outcomes (Hibbard & Greene, 2013).
Patient’s reported symptoms
Post-operative events have been related to patients’ perioperative satisfaction. Specifically, greater satisfaction with outpatient surgery was reported when patients experienced less post-operative infection, inflammation, and pain (Gan et al., 2014; Lemos et al., 2009). In patients who underwent major orthopedic procedures, those who reported greater satisfaction experienced lower levels of pain and perceived that the physician and nurses showed concerned about their pain (Jamison et al., 1997). Patients who were less satisfied experienced persistent pain, nausea, vomiting, and other minor adverse outcomes post-operatively (Hickson et al., 2002; Bjertnaes et al., 2012; Bleich et al., 2009; Hibbard et al., 2004). Pain that was unexpected was associated with decreased satisfaction compared to expected pain (Bain et al., 1999). In addition, psychological distress such as anxiety during the perioperative period can influence post-operative pain and pain control (Perry et al., 1994; Vaughn et al., 2007). Clearly, post-operative symptoms are important to patients’ experiences and the management of emotional and physical symptoms is potential areas of improvement to increase patient perioperative satisfaction (Table 4).
Physicians skills and behaviors
It is no doubt that physicians’ skills and behaviors contribute to patient satisfaction. Those which have been studied in the context of patient satisfaction include technical skills, pain management skills, and physicians’ respect to privacy.
In regards to technical skills, although most physicians tend to consider these skills to be a substantial contributor in patient satisfaction, it has been shown to not be a significant factor (Table 5) (Chung et al., 1999). This may be explained by the difficulties patients have in assessing this surgical skill, and the lack of public data to support this context. Furthermore, the management of postoperative pain can be assessed as a skill. Physicians who are more knowledgeable in pain management and who are better able to adequately control patients’ pain may have more satisfied patients (Meissner et al., 2015). Lastly, protecting patient privacy has been shown to be an important factor to patient satisfaction, particularly within the perioperative setting. When patient privacy and dignity are compromised, patients expressed feeling powerless, vulnerable, and anxiety (Rhodes et al., 2006). Educating and improving physician’s maintenance of patient modesty throughout the perioperative period can improve the patient experience. In total, there are multiple physician skills that if improved can enhance patient satisfaction.
Operational function of the hospital
Important predictors of patient surgical experience include the organizational and structural components of the perioperative environment (Table 6), specifically, the nurse-to-patient ratio (Mazurenko et al., 2015), technical infrastructure (i.e., medical records system) (Mazurenko et al., 2015), and operations of admittance and discharge (Schoenfelder et al., 2010). In an outpatient plastic surgery clinic, patient satisfaction was significantly predicted by efficient clinic operations (e.g., scheduling of appointments and length of time to get an appointment) (Chung et al., 1999). Patients who experienced delays or had longer waiting times between admission, operation, and discharge were more likely to be dissatisfied with their surgical care (Bain et al., 1999; Fregene et al., 2017). Dissatisfied patients felt that there should have been more efficient scheduling and planning of their surgery (Otte, 1996). Patients who felt that their surgical unit was overcrowded were also less satisfied (Hart et al., 1996).
Patients also experience various stressors during hospital admissions that may affect their overall health care experience. A predictor of poor patient satisfaction is the development of the posthospital syndrome (PHS). PHS is described as a transient period of vulnerability after hospitalization where patients are at a higher risk for adverse events due to the experience of repetitive hospital-related stressors (Goldwater et al., 2018; Bueno et al., 2010; Drye et al., 2012). Common stressors include sleep disruptions from machine alarms or frequent health care provider examinations, painful stimuli from vital checks or procedures, and poor nutrition from withholdings of regular meals (Creditor, 1993). Indeed, a recent publication compared patient hospitalization to a painful stimulus animal model (Goldwater et al., 2018). As this animal model may closely resemble those experiences of hospitalized patients, reducing exposure to hospital stresses is warranted to enhance the patient experience.
Interdisciplinary model of care
In a large study completed in 26 hospitals, one of the main predictors of patient satisfaction with their surgical experience was the perceived interpersonal manner of physicians and nurses (Table 7) (Schoenfelder et al., 2010). Many patients liked evidence of efficient communication between health care professionals, which they believe would prevent errors in their care (Lyndon et al., 2011). As an example, patients reported that they preferred instructions received from their hospitalist to align with that of their primary care physician (Mazurenko et al., 2015). A recently implemented interdisciplinary clinical model, the perioperative surgical home (PSH), was also described to enhance patient satisfaction (Kain et al., 2014). PSH is a patient-centered model that improves clinical pathways and reduces system-related variability in the surgical experience. Overall, improvements in the relationships between patient and provider as well as between hospital staff members can enhance patient experience and outcomes.
Non-modifiable factors: demographic and health status predictors
The multifaceted nature of various non-modifiable factors associated with patient experience creates inherent challenges in measuring patient satisfaction scores (Table 8). It has been shown that older patients (variably defined as greater than 50, 65, or 70 years of age) are more likely to be satisfied with their surgical experience compared to younger patients (Caljouw et al., 2008; González et al., 2005; Mira et al., 2009; Capuzzo et al., 2007; Capuzzo et al., 2005; Hawkins et al., 2012; Danforth et al., 2014; Hall & Dornan, 1990; Teunkens et al., 2017; Maurice-Szamburski et al., 2013; Martin et al., 2011). This observation, however, is controversial and some studies have found no correlation with age and patient satisfaction in the surgical setting (Schoenfelder et al., 2010; Hamilton et al., 2013). Similarly, whereas some studies have found that men tend to be more satisfied with surgical care compared to women (Caljouw et al., 2008; Mira et al., 2009; Danforth et al., 2014; Teunkens et al., 2017; Maurice-Szamburski et al., 2013), other studies have found that variations in patient satisfaction with surgical services were not explained by gender (Mira et al., 2009; Schoenfelder et al., 2010; Hamilton et al., 2013). Mixed findings have also been demonstrated with regard to patients’ level of highest education. In a study regarding outpatient surgery, patients with a higher level of education are more likely to be satisfied (Teunkens et al., 2017). However, a mixed study with inpatient and outpatient surgery showed that in both populations, patients with a lower level of education were more satisfied (Mira et al., 2009). With regards to occupation, patients with paid employment were reported to be less satisfied with their perioperative experience compared to retired patients or those with household duties (Caljouw et al., 2008). Patient’s health status also has a wide range of effects on satisfaction in the surgical setting. One study reported that patients with a better health status had higher satisfaction scores (Capuzzo et al., 2007). However, other studies have shown that healthier patients were less satisfied with their surgical care and some have shown no correlation between the two variables (Lehmann et al., 2010; Danforth et al., 2014; Hamilton et al., 2013). Other non-modifiable factors reported in the literature include taking outpatient narcotics and admissions via the emergency department, both of which were related to lower satisfaction with inpatient surgical experience (Johnson et al., 1999; Danforth et al., 2014). Patients who traveled further (> 50 miles) for their surgery were more satisfied than patients who traveled less. Although we cannot alter non-modifiable factors like patient demographics, institutions need to practice caution when evaluating scores between populations that differ significantly with regard to such characteristics.
Interventions to improve patient satisfaction
Clinician communication skills
Various hospital intervention programs have been implemented to improve patients’ perioperative experiences. One training program taught anesthesiologists how to establish a welcoming atmosphere, elicit the patient’s concerns about anesthesia and surgery, demonstrate empathy verbally and non-verbally, involve the patient in decision-making, and conclude the visit by reassuring the patient of ongoing care. This communication skill training increased patient satisfaction and decreased patient anxiety with surgery (Harms et al., 2004). Many studies conducted in non-surgical settings have confirmed the relationship that improving physician communication and delivery of information improves patients’ experiences (Boissy et al., 2016; Bredart et al., 2005; Levinson & Lesser, 2010).
Information provision to patients
Provision of valuable and appropriately tailored preoperative information can facilitate patients’ active involvement in their care and can contribute to an increase in satisfaction. Various modalities of information provision to patients during the pre-operative visit have been attempted. Along with standard verbal information, the implementation of additional written information in the form of pamphlets has been shown to improve satisfaction (Angioli et al., 2014; Straessle, 2011). And the use of an informational website or a supplemental video and written brochure improve satisfaction scores (Snyder-Ramos et al., 2005; Hering et al., 2005). One intervention showed that providing detailed drug information leaflets for anesthetic drugs was not thought necessary by many patients but did not increase pre-operative state anxiety (Lee & Gin, 2005). Thus, providing surgical patients with more information than necessary through the use of multiple modalities is effective in improving satisfaction with their surgical experience and does not result in negative consequences.
Operational function of the hospital
In regard to hospital functioning, one intervention program staggered patient arrival times, had the first surgical patient of the day arrive earlier, assigned a single point of contact for patients, and informed patients of the possibility of a delay on the day of the surgery during pre-operative visits. These changes increased the percentage of satisfied patients and also led to shorter waiting times, better dissemination of information, and fewer patients reporting hunger or thirst (Fregene et al., 2017). Organizations have also provided more training for their staff members based on patient satisfaction results and trained nurse practitioners to complete all initial assessments, eliminating multiple providers and repeated medical questioning. These improvements enhanced patient satisfaction in domains of pre-operative experience, courtesy and efficiency of the clinic staff, and waiting time (Harnett et al., 2010).
Optimizing patient recovery
The Enhanced Recovery After Surgery (ERAS) protocol and the Perioperative Surgical Home (PSH) are innovative perioperative management strategies used to reduce the length of hospital stay, costs, and complications (Kain et al., 2014; Melnyk et al., 2011). ERAS includes preoperative counseling, optimization of nutrition, scheduled analgesic regimens, and early mobilization. A systematic review completed in 2010 found that patients managed with ERAS reported reduced pain after surgery. However, it also found no difference in patient satisfaction after ERAS compared to the conventional recovery protocol (Khan et al., 2010). In another study, patient satisfaction as measured by Press Ganey was reported to improve significantly in patients following ERAS after colorectal surgery (Thiele et al., 2015).
The patient-centered approach of the PHS model aims to coordinate perioperative care within a multidisciplinary team (Kain et al., 2014). This model incorporates certain components of ERAS, but it is a broader concept. Studies have shown that patients who were treated with the PSH pathway had shorter lengths of hospital stays and lower unplanned hospital admissions compared with the standard pathway (Qiu et al., 2017). Although the result data is still emerging, ERAS and PSH are examples of effective interventions that can improve patient satisfaction in specific populations.
We identified a number of variables that if modified can improve patient satisfaction scores and as such clinical outcomes and financial reimbursement of the hospital. These variables include clinician communication skills, information provision to patients, physician skills and behaviors, and a multidisciplinary patient care approach. Some non-modifiable predictors such as age and baseline health status were shown to impact patient satisfaction scores. Although these patient variables cannot be modified, it is important to understand the measured outcomes of a specific institution within this context. That is, organizations ideally should be compared to “like-organizations,” but unfortunately, this is not a common practice. Lastly, we have identified interventions that have been successful in improving patient satisfaction scores. Considering the multidimensional aspects of patient satisfaction, a team-focused approach should be implemented when attempting interventions to improve satisfaction. We suggest that readers engage in a discussion with patient experience leaders in their own organizations and understand how they can enhance patient satisfaction scores while modifying practices and behaviors that are in their own control.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Abtahi AM, Presson AP, Zhang C, Saltzman CL, Tyser AR. Association between orthopaedic outpatient satisfaction and non-modifiable patient factors. J Bone Jt Surg - Am Vol. 2014 Jul 1;97(13):1041–1048.
Agency for Healthcare Research & Quality [Internet]. [cited 2018 Aug 10]. Available from: https://www.ahrq.gov/
Angioli R, Plotti F, Capriglione S, Aloisi A, Aloisi ME, Luvero D, et al. The effects of giving patients verbal or written pre-operative information in gynecologic oncology surgery: a randomized study and the medical-legal point of view. Eur J Obstet Gynecol Reprod Biol. 2014.
Auquier P, Pernoud N, Bruder N, Simeoni MC, Auffray JP, Colavolpe C, et al. Development and validation of a perioperative satisfaction questionnaire. Anesthesiology. 2005.
Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Qual Health Care. 1999 Jun;8(2):86–91.
Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communications skills on patient satisfaction; Recall, and adherence. J Chronic Dis. 1984;37(9–10):755–64.
Bernard SA, Chelminski PR, Ives TJ, Ranapurwala SI. Management of pain in the united states-a brief history and implications for the opioid epidemic. Heal Serv insights. 2018;11:1178632918819440.
Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008;27:759–69.
Bjertnaes OA, Sjetne IS, Iversen HH. Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations. BMJ Qual Saf. 2012 Jan;21(1):39–46.
Bleich SN, Ozaltin E, Murray CJL. How does satisfaction with the health-care system relate to patient experience? Bull World Health Organ. 2009 Apr 1;87(4):271–8.
Boissy A, Windover AK, Bokar D, Karafa M, Neuendorf K, Frankel RM, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul 26;31(7):755–61.
Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011 Jan;17(1):41–8.
Bredart A, Bouleuc C, Dolbeault S. Doctor-patient communication and satisfaction with care in oncology. Curr Opin Oncol. 2005 Jul;17(4):351–4.
Bueno H, Ross JS, Wang Y, Chen J, Vidán MT, Normand SLT, et al. Trends in length of stay and short-term outcomes among medicare patients hospitalized for heart failure, 1993-2006. JAMA - J Am Med Assoc. 2010;303(21):2141–7.
Caljouw MAA, van Beuzekom M, Boer F. Patient’s satisfaction with perioperative care: development, validation, and application of a questionnaire. Br J Anaesth. 2008 May;100(5):637–44.
Capuzzo M, Gilli G, Paparella L, Gritti G, Gambi D, Bianconi M, et al. Factors predictive of patient satisfaction with anesthesia. Anesth Analg. 2007 Aug;105(2):435–42.
Capuzzo M, Landi F, Bassani A, Grassi L, Volta CA, Alvisi R. Emotional and interpersonal factors are most important for patient satisfaction with anaesthesia. Acta Anaesthesiol Scand. 2005 Jul;49(6):735–42.
Chanthong P, Abrishami A, Wong J, Herrera F, Chung F. Systematic review of questionnaires measuring patient satisfaction in ambulatory anesthesia. Anesthesiology. 2009 May 1;110(5):1061–7.
Chung KC, Hamill JB, Kim HM, Walters MR, Wilkins EG. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg. 1999 Jan;42(1):56–60.
CMS. Center of Medicare and Medicaid Services (CMS) [Internet]. [cited 2018 Aug 20]. Available from: https://www.cms.gov/
Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219–23.
Dalal AK, Dykes PC, Collins S, Lehmann LS, Ohashi K, Rozenblum R, et al. A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation. J Am Med Inform Assoc. 2016 Jan;23(1):80–7.
Danforth RM, Pitt HA, Flanagan ME, Brewster BD, Brand EW, Frankel RM. Surgical inpatient satisfaction: what are the real drivers? In. Surgery. 2014:328–35.
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.
Drye EE, Normand SLT, Wang Y, Ross JS, Schreiner GC, Han L, et al. Comparison of hospital risk-standardized mortality rates calculated by using in-hospital and 30-day models: an observational study with implications for hospital profiling. Ann Intern Med. 2012;156(1):19–26.
Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012 Mar 12;172(5):405–11.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder ÉL. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Ann Intern Med. 2003 Feb 18;138(4):288–98.
Forsberg A, Vikman I, Wälivaara BM, Engström Å. Patients’ perceptions of quality of care during the perioperative procedure. J Perianesth Nurs. 2015 Aug;30(4):280–9.
Freed LH, Ellen JM, Irwin CE, Millstein SG. Determinants of adolescents’ satisfaction with health care providers and intentions to keep follow-up appointments. J Adolesc Health. 1998 Jun;22(6):475–9.
Fregene T, Wintle S, Venkat Raman V, Edmond H, Rizvi S. Making the experience of elective surgery better. BMJ Open Qual. 2017 Aug 1;6(2):e000079.
Fung D, Cohen M. What do outpatients value most in their anesthesia care? Can J Anesth. 2001 Jan;48(1):12–9.
Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014 Jan 15;30(1):149–60.
Gebremedhn EG, Lemma GF. Patient satisfaction with the perioperative surgical services and associated factors at a University Referral and Teaching Hospital, 2014: a cross-sectional study. Pan Afr Med J. 2017;27:176.
Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Measuring hospital care from the patients’ perspective: an overview of the CAHPS?? Hospital Survey development process. 2005;40.
Goldwater DS, Dharmarajan K, McEwen BS, Krumholz HM. Is posthospital syndrome a result of hospitalization-induced allostatic overload? J Hosp Med. 2018;13(5).
González N, Quintana JM, Bilbao A, Escobar A, Aizpuru F, Thompson A, et al. Development and validation of an in-patient satisfaction questionnaire. Int J Qual Health Care. 2005 Jun 1;17(6):465–72.
Haley DR, Zhao M, Spaulding A, Hamadi H, Xu J, Yeomans K. The influence of hospital market competition on patient mortality and total performance score. Health Care Manag (Frederick). 2016;35(3):220–30.
Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811–8.
Hamilton DF, Lane JV, Gaston P, Patton JT, MacDonald D, Simpson AHRW, et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open. 2013 Jan 1;3(4):e002525.
Harms C, Young JR, Amsler F, Zettler C, Scheidegger D, Kindler CH. Improving anaesthetists’ communication skills. Anaesthesia. 2004 Feb;59(2):166–72.
Harnett MJP, Correll DJ, Hurwitz S, Bader AM, Hepner DL. Improving efficiency and patient satisfaction in a tertiary teaching hospital preoperative clinic. Anesthesiology. 2010 Jan 1;112(1):66–72.
Hart J, Neiman V, Chaimoff C, Wolloch Y, Djaldetti M. Patient satisfaction in two departments of surgery in a community hospital. Isr J Med Sci. 1996 Dec;32(12):1338–43.
Haskard Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34.
Hawkins RJ, Swanson B, Kremer MJ. An integrative review of factors related to patient satisfaction with general anesthesia care. AORN J. 2012 Oct;96(4):368–76.
Heidegger T, Husemann Y, Nuebling M, Morf D, Sieber T, Huth A, et al. Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmaking among six hospitals in Switzerland and Austria. Br J Anaesth. 2002 Dec;89(6):863–72.
Hepner DL, Bader AM, Hurwitz S, Gustafson M, Tsen LC. Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesth Analg. 2004 Apr;98(4):1099–105.
Hering K, Harvan J, D’Angelo M, Jasinski D. The use of a computer website prior to scheduled surgery (a pilot study): impact on patient information, acquisition, anxiety level, and overall satisfaction with anesthesia care. AANA J. 2005 Feb;73(1):29–33.
Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff. 2013 Feb;32(2):207–14.
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004 Aug;39(4 Pt 1):1005–26.
Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. J Am Med Assoc. 2002;287(22):2951–7.
Hussey PS, Wertheimer S, Mehrotra A. The association between health care quality and cost a systematic review. Ann Intern Med. 2013;158:27–33.
Inglis S, Farnill D. The effects of providing preoperative statistical anaesthetic-risk information. Anaesth Intensive Care. 1993 Dec;21(6):799–805.
Jamison RN, Ross MJ, Hoopman P, Griffin F, Levy J, Daly M, et al. Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain. 1997 Sep;13(3):229–36.
Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008 Oct 30;359(18):1921–31.
Johnson RC, Pye JK, Scriven MW, Billings PJ, Wood C, Crumplin MKH. Patients’ perception of surgical services in a district general hospital. Br J Surg. 1999 Dec;86(12):1549–55.
Kahn SA, Iannuzzi JC, Stassen NA, Bankey PE, Gestring M. Measuring satisfaction: factors that drive hospital consumer assessment of healthcare providers and systems survey responses in a trauma and acute care surgery population. Am Surg. 2015 May;81(5):537–43.
Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg. 2014 May;118(5):1126–30.
Kain ZN, Wang SM, Caramico LA, Hofstadter M, Mayes LC. Parental desire for perioperative information and informed consent: a two-phase study. Anesth Analg. 1997 Feb;84(2):299–306.
Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. Timmer A, editor. PLoS One. 2014 Apr 9;9(4):e94207.
Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of life and patient satisfaction with enhanced recovery protocols. Color Dis. 2010 Dec;12(12):1175–82.
Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship between meeting patients’ information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care. 1996 Jan 1;8(5):447–56.
Lee A, Gin T. Educating patients about anaesthesia: effect of various modes on patients’ knowledge, anxiety and satisfaction. Curr Opin Anaesthesiol. 2005;18:205–8.
Lee D. Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction. Circulation. 2008.
Lehmann M, Monte K, Barach P, Kindler CH. Postoperative patient complaints: a prospective interview study of 12,276 patients. J Clin Anesth. 2010 Feb;22(1):13–21.
Leinonen T, Leino-Kilpi H, Ståhlberg MR, Lertola K. The quality of perioperative care: development of a tool for the perceptions of patients. J Adv Nurs. 2001 Jul 22;35(2):294–306.
Lemos P, Pinto A, Morais G, Pereira J, Loureiro R, Teixeira S, et al. Patient satisfaction following day surgery. J Clin Anesth. 2009 May;21(3):200–5.
Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Vol. 29, Health Aff Health Affairs; 2010. p. 1310–1318.
Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol. 2011;205(2):91–6.
Mann RK, Siddiqui Z, Kurbanova N, Qayyum R, Qayyum R. Effect of HCAHPS reporting on patient satisfaction with physician communication. J Hosp Med. 2016 Feb 1;11(2):105–10.
Martin L, Presson AP, Zhang C, Ray D, Finlayson S, Glasgow R. Association between surgical patient satisfaction and nonmodifiable factors. J Surg Res. 2017 Jun;214:247–53.
Martin SR, Fortier MA, Kain DI, Tan ET, Huszti H, Wahi A. Desire for perioperative information and parental ethnicity. Paediatr Anaesth. 2011;21(10):1046–51.
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999 Jan 20;281(3):283–7.
Maurice-Szamburski A, Bruder N, Loundou A, Capdevila X, Auquier P. Development and validation of a perioperative satisfaction questionnaire in regional anesthesia. Anesthesiology. 2013 Jan;118(1):78–87.
Mazurenko O, Zemke D, Lefforge N, Shoemaker S, Menachemi N. What determines the surgical patient experience? Exploring the patient, clinical staff, and administration perspectives. J Healthc Manag. 2015;60:332–46.
McBride CA, Shugars DA, DiMatteo MR, Lepper HS, O’Neil EH, Damush TM. The physician’s role. Views of the public and the profession on seven aspects of patient care. Arch Fam Med. 1994 Nov;3(11):948–53.
Meissner W, Coluzzi F, Fletcher D, Huygen F, Morlion B, Neugebauer E, et al. Improving the management of post-operative acute pain: priorities for change. Curr Med Res Opin. 2015 Nov 2;31(11):2131–43.
Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J. 2011 Oct;5(5):342.
Mira JJ, Tomás O, Virtudes-Pérez M, Nebot C, Rodríguez-Marín J. Predictors of patient satisfaction in surgery. Surgery. 2009 May;145(5):536–41.
Myles PS, Williams DL, Hendrata M, Anderson H, Weeks AM. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. Br J Anaesth. 2000;84(1):6–10.
Obama B. United States health care reform: progress to date and next steps. JAMA - Journal of the American Medical Association. American Medical Association; 2016, Vol. 316. p. 525–532.
OCED. OECD Health Statistics 2018 [Internet]. 2018 [cited 2018 Aug 20]. Available from: http://www.oecd.org/els/health-systems/health-data.htm
Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med. 2010;170(15):1302–7.
Oswald N, Hardman J, Kerr A, Bishay E, Steyn R, Rajesh P, et al. Patients want more information after surgery: a prospective audit of satisfaction with perioperative information in lung cancer surgery. J Cardiothorac Surg. 2018 Feb 1;13(1):18.
Otte DI. Patients’ perspectives and experiences of day case surgery. J Adv Nurs. 1996 Jun;23(6):1228–37.
Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plann. 1983;6(3–4):185–210.
Perry F, Parker RK, White PF, Clifford PA. Role of psychological factors in postoperative pain control and recovery with patient-controlled analgesia. Clin J Pain 1994 Mar;10(1):57–63; discussion 82-5.
Qiu C, Rinehart J, Nguyen VT, Cannesson M, Morkos A, LaPlace D, et al. An ambulatory surgery perioperative surgical home in kaiser permanente settings. Anesth Analg. 2017 Mar;124(3):768–74.
Rhodes L, Miles G, Pearson A. Patient subjective experience and satisfaction during the perioperative period in the day surgery setting: a systematic review. Int J Nurs Pract. 2006 Aug;12(4):178–92.
Roseman D, Osborne-Stafsnes J, Amy CH, Boslaugh S, Slate-Miller K. Early lessons from four “Aligning Forces for Quality” communities bolster the case for patient-centered care. Health Aff. 2013 Feb 2;32(2):232–41.
Sacks GD, Lawson EH, Dawes AJ, Russell MM, Maggard-Gibbons M, Zingmond DS, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality. JAMA Surg. 2015 Sep 1;150(9):858.
Schoenfelder T, Klewer J, Kugler J. Factors associated with patient satisfaction in surgery: The role of patients’ perceptions of received care, visit characteristics, and demographic variables. J Surg Res. 2010 Nov 1;164(1):e53–9.
Sequist TD, Schneider EC, Anastario M, Odigie EG, Marshall R, Rogers WH, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008 Nov;23(11):1784–90.
Sitzia J. How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care. 1999 Aug 1;11(4):319–28.
Snyder-Ramos SA, Seintsch H, Böttiger BW, Motsch J, Martin E, Bauer M. Patient satisfaction and information gain after the preanesthetic visit: a comparison of face-to-face interview, brochure, and video. Anesth Analg. 2005 Jun;100(6):1753–8.
Squires D, Anderson C. Issues in international health policy U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. Vol. 15, The Commonwealth Fund. 2015 Oct.
Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423–33.
Straessle. Is a pre-anaesthetic information form really useful? Acta Anaesthesiol Scand. 2011;55(5):517–23.
Teunkens A, Vanhaecht K, Vermeulen K, Fieuws S, Van de Velde M, Rex S, et al. Measuring satisfaction and anesthesia related outcomes in a surgical day care centre: a three-year single-centre observational study. J Clin Anesth. 2017 Dec;43:15–23.
Tevis SE, Kennedy GD, Kent KC. Is there a relationship between patient satisfaction and favorable surgical outcomes? , Ann Surg. NIH Public Access; 2015.Vol. 49 p. 221–233.
Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015 Apr;220(4):430–43.
Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save medicare money and bolster episode-based payment models. Health Aff. 2016 Sep 2;35(9):1681–9.
Tsai TC, Orav EJ. Jha AK. Patient satisfaction and quality of surgical care in US hospitals. 2015 Jan;261(1):2–8.
Vaughn F, Wichowski H, Bosworth G. Does preoperative anxiety level predict postoperative pain? AORN J. 2007 Mar 1;85(3):589–604.
Werner RM, Bradlow ET. Relationship between medicare’s hospital compare performance measures and mortality rates. JAMA. 2006 Dec 13;296(22):2694.
Ethics approval and consent to participate
Consent for publication
Zeev N. Kain serves as a speaker or coach to Studer Group, Edwards Lifesciences, Medtronics and Medacta. His research is supported by the National Institutes of Health (NICHD). The other authors declared that they have no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Trinh, L.N., Fortier, M.A. & Kain, Z.N. Primer on adult patient satisfaction in perioperative settings. Perioper Med 8, 11 (2019) doi:10.1186/s13741-019-0122-2
- Adult patient satisfaction
- Clinical communication
- Information provision