Part One of a Three-Part Series

H

ealthcare providers, regulators, and health services researchers have judged patient satisfaction to be an effective measure of medical care quality.1-3 Many nursing homes across the country are interested in achieving the highest level of client satisfaction and are currently implementing quality improvement initiatives aimed at increasing resident and family satisfaction at their facility. By and large, however, client satisfaction is not as commonly monitored in long-term care facilities as it is in hospitals. Researchers involved in health system design, long-term care policy, and performance report cards suggest that long-term care leaders follow the hospital approach to quality concerns and prioritize client-centered performance measures in their performance review systems.4
       The value of measuring and improving client satisfaction in long-term care operations becomes evident when client satisfaction is recognized as an indicator of quality care, a component of quality care, and an outcome of quality care. In addition to being a legitimate measure of quality of care, patient satisfaction has been linked to better compliance with treatment plans;5 reduced willingness to sue;6 and financial payoffs (see Table 1).7
       This, the first in a series of articles highlighting the current state of resident and family satisfaction in our nation's long-term care facilities, focuses on nursing home residents' ratings of nurses, certified nursing aides (CNAs), and other staff members.
       Press Ganey Associates, the healthcare industry's largest satisfaction measurement firm, collected data from 6,902 residents in 127 nursing homes across the country from January to December 2001. Residents were sent a standardized survey asking about the most central aspects of their nursing home experience, ranging from the admission process to meals to staff evaluations. Residents completed the surveys on their own or, when needed, with the assistance of a family member, under the guarantee that their responses would be kept confidential. Their feedback offers valuable insight into the customers' perceptions of care at nursing homes, capturing feelings often not discussed in face-to-face interactions for fear of reprisals.
       The results of last year's monitoring are clear: The interpersonal relationships between the residents and the CNAs and residents and the nurses emerged as the service areas most highly associated with resident satisfaction.
       The three issues most important to residents are that both CNAs and nurses:
- Provide explanations of their care
- Be responsive to the residents' own ideas about their care
- Treat them with dignity.
       In essence, residents are asking to be included as active participants in their own care. They are simply requesting information about what is being done to them and why, what to expect, and further, for their care providers to show a genuine interest in their own ideas and suggestions about how they'd like to be cared for. For residents to feel involved in their own care, will likely require an ongoing dialog between resident and care providers, rather than an initial explanation of the care plan upon admission. Because of the strong correlations between these issues and overall satisfaction (correlation coefficients range from 0.65-0.74), facilities that excel in these areas will also be characterized by highly satisfied residents. Most encouraging is that these behaviors can be defined and developed through training. While residents consider these behaviors equally important in their nurses and aides, they express significantly greater satisfaction with the nurses' behavior compared to the CNAs' behavior (see Graph 1).
       Overall, nurses earned the highest ratings of all care dimensions surveyed (see Graph 2). The discrepancy between resident satisfaction with aides and nurses is dramatic.
       Of all the issues covered on the survey, residents expressed the most satisfaction with the friendliness and courtesy of the staff members, thereby pinpointing one of the industry's service strengths. Not only were ratings high (although there is still room for improvement), they were also rather consistent, suggesting that residents across the country share similar feelings (see Graph 3). "Friendliness of the nurses" was the single highest scoring item on the survey.
       Staff friendliness not only makes for more positive daily interactions but also plays a key role in obtaining customer referrals. The issue most highly correlated with the likelihood of residents recommending their nursing home to friends or family is how the staff treats visitors. If residents perceive that staff members are friendly to visitors and treat them well, they are very likely to give positive word of mouth referrals to the facility, which is undoubtedly the most effective form of marketing.
       The areas of marked dissatisfaction tend to relate to facility issues with three glaring exceptions that relate to staff. Indeed, the lowest scoring item on the survey was aides' responsiveness to call lights. This issue also showed the greatest variability, indicating that resident experiences across the county vary greatly on this matter. Taken together, 70 percent of residents were less than fully satisfied with how quickly aides responded when they used their call button to ask for assistance.
       The other lowest scoring staff evaluations relate to management. Sixty-five percent of residents were not fully satisfied with how receptive management is to their ideas. Another 70 percent of residents were not fully satisfied with the availability of doctors on campus. These three issues (aides' responsiveness to call lights; management being receptive to ideas; availability of doctors) are, for the industry as a whole, the issues that should be prioritized for improvement, because they received low marks and were deemed very important by residents relative to other aspects of their nursing home experience. On average, investing in these areas would be the most efficient use of limited resources, because improvements in these areas would be accompanied by the greatest increases in resident satisfaction ("Get the biggest bang for your buck!").
       In addition to providing around-the-clock medical attention, long-term care providers have a broader set of service obligations to their customers. Facilities that can boast high resident satisfaction are more likely to remain financially viable in areas of intense competition for market share, but more importantly, listening to your residents' wants and needs is the right thing to do.