Systematic Review

Patient Satisfaction in Pediatric Surgical Care: A Systematic Review Alexandra G. Espinel, MD1, Rahul K. Shah, MD2, Michael E. McCormick, MD3, Paul R. Krakovitz, MD4, and Emily F. Boss, MD, MPH5

Otolaryngology– Head and Neck Surgery 2014, Vol. 150(5) 739–749 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: DOI: 10.1177/0194599814527232

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Received November 25, 2013; revised January 31, 2014; accepted February 18, 2014.

Abstract Objective. This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care.


Data Sources. PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials. Review Methods. We queried 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient or parent satisfaction or experience of care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent or patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles. Results. The initial search yielded 4748 publications (1503 duplicates), of which 170 underwent full-text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (3/35), parent (23/35), or both (9/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (8), by satisfaction tools (8), or by nonstandard institutional or author-developed tools (19). Experience was measured in the outpatient (7), preoperative (11), operative (14), and postoperative (3) care settings. Specific findings were unique to setting; however, in many studies higher satisfaction correlated with education/information giving, health care provider interpersonal behaviors, and facile/efficient care processes. Conclusion. The patient experience of care is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Findings related to patient satisfaction and experience of care may be limited due to lack of measurement using validated tools. Findings from this review may bear significance as patient experience measures become routinely integrated with quality and reimbursement. Keywords patient satisfaction, patient experience of care, patientcentered care, family-centered care, pediatric surgery, service excellence, quality improvement

The Institute of Medicine (IOM) defines patient-centered care as care that is respectful of and responsive to individual patient preferences, needs, and values while ensuring that patient values guide clinical decisions.1 Patient-centered care is the foundation of exceptional patient and family inpatient experiences per the Institute for Healthcare Improvement (IHI).2 The American Academy of Pediatrics (AAP) currently recommends that patient- and family-centered care be incorporated into all aspects of pediatric surgical operations.3 As well, the AAP recognizes the challenge of assessing quality of care in this population. The crux of the pediatric care experience is measured by the parents’ involvement in treatment as well as ultimate medical decision making. Further, surgical care adds complexity to the relationship between parents and providers, as multiple teams interact with the family in numerous settings. Thus, the pediatric surgical care experience is multifaceted and often complex to evaluate. The IHI notes that the exact definition of patient-centered care varies with the unique needs of the population receiving the care.2 To truly to provide such care, the needs and views of this unique population need to be examined.

1 Department of Otolaryngology, George Washington University, Washington, DC, USA 2 Department of Otolaryngology, Children’s National Medical Center, Washington, DC, USA 3 Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA 4 Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA 5 Department of Otolaryngology, Johns Hopkins University, Baltimore, Maryland, USA

This article was presented at the 2013 AAO-HNSF Annual Meeting and OTO EXPO; September 29–October 3, 2013; Vancouver, British Columbia, Canada. Corresponding Author: Emily F. Boss, MD, MPH, Department of Otolaryngology, Johns Hopkins University, 601 N. Caroline St., 6th Floor, Baltimore, MD 21287, USA. Email: [email protected]

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Further, the AAP strongly supports measurement of quality indicators, such as patient satisfaction, with the ultimate goal of improving patient outcomes.4 The IOM cites patientcentered care as 1 of 6 aims for improvement in health care, recognizing that customization of care according to patient needs and values is essential to achieving this goal.1 In the realm of pediatric surgical care, standardization of measurement for patient experience and satisfaction is lacking. Understanding the forces driving patient satisfaction and experience of care in this population may ultimately improve quality of care as measured by the tenant of patient and family centeredness and allow practitioners to fulfill the goals set out by the AAP and IOM. In this report, we sought to synthesize the evidence-based findings related to use of patient satisfaction as a process measure in pediatric surgical care.

Methods Study Design

full-text review in a stepwise fashion exactly as the other papers.

Eligibility Criteria We selected papers published in the last 20 years: January 1, 1993, to January 30, 2013. We included studies specific to surgical fields in which children were the primary patient population (at least 50% of the population studied) and the central theme involved patient or parent satisfaction, experience, or communication as a measure of surgical quality or operations. Review articles, commentaries, letters to the editor, case reports, meeting abstracts only, non–Englishlanguage papers, and articles referring to satisfaction or experience of care specific to a disease or diagnosis were excluded. We did not exclude studies based outside of the United States as many international studies have evaluated patient experience of care, and we felt that their findings would be applicable to our study.

Data Extraction

We conducted a qualitative systematic review of the published literature to broadly investigate patient satisfaction as a process measure in pediatric surgical care. A quantitative meta-analysis was not performed due to the heterogeneous designs of the selected studies. We adhered to the PRISMA checklist and statement recommendations during the conduct of this systematic review.5 In January 2013 we searched 4 large literature sources: PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). The principle electronic search strategy was designed for use in PubMed and then tailored for the other electronic databases in a similar fashion. The initial search incorporated use of Medical Subject Headings (MeSH) in addition to key text words deducted from relevant publications. The MeSH terms used were ‘‘patient centered care,’’‘‘patient satisfaction,’’‘‘consumer satisfaction,’’‘‘surgical procedures, operative,’’ and ‘‘general surgery.’’ A medical librarian helped to develop the search strategies and reviewed them for accuracy and thoroughness. Results of all electronic searches were imported into RefWorks-COS 2.0 web-based bibliographic management software. At least 2 authors independently reviewed each publication’s abstract for inclusion in full-text review. A third reviewer evaluated abstracts for which consensus was not met. Papers included by at least 2 authors for eligibility underwent full-text review. If no abstract was present, the paper was included for full-text review. Upon review of the full-text articles, we noted a large proportion of otolaryngology papers, while several pediatric surgical subspecialties (orthopedics, urology, plastic surgery, and neurosurgery) were not represented. To compensate for this sampling error, we conducted a new search by modifying our first search to include subject headings specific to other surgical subspecialties. The same eligibility criteria applied to these additional articles, and they underwent abstract and

A review form was generated to collect study characteristics and the relevant data necessary to address the study questions. Team members conceptualized the form based on the data required to address study questions. The form was used for 5 articles and then reviewed and revised by the study team to ensure that all relevant data were collected. We collected the following data for each article: country where study was conducted, surgical specialty, study design, study setting, surgical setting in which patient experience was assessed (outpatient, inpatient, preoperative, postoperative), patient population, number of participants, study population focus, the intervention objective and methods, tool used to measure satisfaction or experience, additional outcome measures, findings, conclusions, and limitations. Two reviewers each independently completed the review form. The data collected by each reviewer were compiled and checked for accuracy and completeness. Any discrepancies between the 2 reviewers were resolved by additional review of the paper and discussion among the reviewers.

Data Synthesis We classified the studies based on setting (preoperative, operative, postoperative, and outpatient) and created summary tables of results. We identified several potential groups in which to categorize the findings; however, grouping them based on setting was felt to be the most logical division, as patient expectations may vary with setting. Next, we looked for the relationships between the interventions and outcomes to establish pooled findings related to those factors that both negatively and positively affected the patient and family experience. Additionally, we evaluated the instrument used to measure satisfaction and experience.

Evidence Grading The strength of evidence from each study was graded based on the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) level of evidence guidelines.6

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Table 1. Summary of Selected Study Characteristics. Records idenfied through database searching (n = 4700)

Addional records idenfied through other sources (n = 48)




Records aer duplicates removed (n = 3245)

Records screened (n = 3245)

Records excluded (n = 3075)

Full-text arcles assessed for eligibility (n = 170)

Full-text arcles excluded because children not primary populaon or experienceof care specific to a disease or diagnosis (n = 135)

Studies included in qualitave synthesis (n = 35)

Figure 1. Summary of literature search and review for eligible articles (n indicates number of articles or citations at each step).

Results Literature Search and Review Process Figure 1 summarizes the results of the literature search and review process.5 We identified 4746 citations through the electronic data base search (PubMed n = 2338, Scopus n = 1726, CINAHL n = 549, and CENTRAL n = 65), hand search (n = 48), and the additional PubMed search with key words specific to urology and orthopedics (n = 22). We reviewed 3245 abstracts after duplicates (n = 1503) were removed. In total, 170 met criteria for full-text review, and 35 papers7-41 were ultimately included in the study. The most common reasons for exclusion were that a study was not focused on the pediatric population or it evaluated patient satisfaction related to outcomes of a specific diagnosis or procedure.

Study Characteristics Table 1 demonstrates a summary of selected demographic information for the 35 included studies. The majority of studies were from the United States. The setting of the experience evaluated was most commonly operative (preoperative, operating room, and postanesthesia care unit) (n = 14) followed by preoperative (clinic and preoperative nursing care) (n = 11). In 66% (n = 23) of the studies included, patient experience was evaluated by only parental measures. Child behaviors and child-specific measures without any study of parental measures were used in 3 studies. Nonvalidated, author-generated tools were used to measure experience and satisfaction in the majority (n = 19) of studies. Validated satisfaction surveys were used in 8 investigations, while a combination of nonstandardized satisfaction tools and validated self-assessment measures were used in 8.

Selected Demographic Domain

Articles, No. (Total N = 35)

Region North Americaa Europeb Asiac Australia Setting Outpatient Preoperative Perioperative Postoperative Specialty Anesthesia Otolaryngology Pediatric surgery Urology Multiple specialties Obstetrics Not specified Experience evaluated Child Parent Both Measure of outcome Validated self-assessment tool combined with nonstandard satisfaction measurement tool Validated satisfaction survey Nonstandard author developed tool Level of evidence 1b 2b 2c 3b 4

17 13 2 2 7 11 14 3 7 15 5 2 3 1 2 3 23 9 8

8 19 7 5 10 2 11


United States (n = 17) and Canada (n = 2). Norway (n = 1), United Kingdom (n = 3), Ireland (n = 2), Sweden (n = 3), Italy (n = 1), Greece (n = 1), and Germany (n = 2). c China (n = 1) and Japan (n = 1). b

Approximately one-third (n = 11) of the studies were observational cohort studies that did not use statistical analyses, resulting in a grade 4 level of evidence. Another onethird (n = 10) consisted of outcomes research (level 2c). Seven studies were randomized controlled trials.

Publication Dates The year of publication ranged from 1994 to 2013 (Figure 2). Sixteen (46%) of the studies had been published since 2010.

Patient Experience in the Preoperative Setting Table 2 summarizes findings for the 11 studies evaluating the preoperative surgical experience. Six of these studies

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Year of Publication


2005 Out Patient Peri Operative 2000 Post Operative Pre Operative


Parhiscar, A. Ovchinsky, A. Shivji, S. Boss, E.F. Margaritis, E. Zopf, D. Boss, E.F. Blesch, P. Hicklin, L. Moen, M.C, Palermo, T.M. Jacobucci, T. Varughese, A.M. Wennstrom, B. Grisel, J. Kain, Z. Micheli, A. Barnett, S.J. Wennstrom, B. Reismann, M. Schiff, J.H. Birtwistle,L. Ford, K. Kassmann, B.P. Ellerton, M. Hatava, P. Spencer, C. Li, H.C.W. O’Conner‐Von, S. Wakimizu, R. Chantry, C.J. Adams, M.T. Fincher, W. O’Shea, M Oosthuizen, J.C.


First Author

Figure 2. Publication year of papers evaluating patient experience as an outcome measure for patient experience in pediatric surgical settings.

were randomized clinical trials, 3 were case-control studies, and 2 were observational studies. All of the studies evaluating experience of care in the preoperative setting investigated the impact of various preoperative educational methods on the care experience of parents and children. The educational methods included a preoperative educational program using a visit to the hospital in 4 studies,31,32,39,40 therapeutic play for children,34 video educational tools,37 and supplemental home materials in 4 studies.33,35,36,41 Of the 7 studies that evaluated the impact of the intervention on anxiety, 5 studies (71%) demonstrated decreased child and parent anxiety in those who received preoperative education, all of which were statistically significant for the children (n = 1), adults (n = 1), or both (n = 3). Three of these demonstrated a positive correlation between child and adult anxiety. Validated tools were used to measure anxiety in all the studies. Satisfaction was high in all of the studies, with statistically significant higher satisfaction in the intervention group in 3 studies (27%). Positive correlations were noted between satisfaction and increased parental and child knowledge about the operative process, which was achieved through multidimensional programs including role-play, preadmission hospital visits, and familiarization with hospital equipment and staff roles. Additional information provided verbally or via written handouts did not appear to change satisfaction. Those subjects who were dissatisfied often did not feel they had enough information. No authors used validated tools to measure satisfaction.

Patient Experience in the Operative Setting Table 3 contains the summary of findings for the 14 studies evaluating the operative surgical experience. One was a

randomized controlled trial, 4 were case-control, 8 were observational, 1 was a cross-sectional survey, and 1 was a retrospective review. The majority of investigators15,16,18-27(n = 11/13) examined general care and the operative experience. Specific aspects of the experience were examined in 5 of these 11 studies. They included day case surgery,15 same-day surgical evaluation and procedure,24 continuity of care,25 fast-track surgical care,26 experience in the ambulatory surgery center,21 and experiences of children with disabilities.27 Two authors14,17 evaluated the impact of parental presence for anesthesia induction on the overall experience of care. Overall satisfaction was high in all of the studies, with only 1 study demonstrating a statistically significant difference in satisfaction when the experiences of families of children with disabilities were compared with those without.27 Associations were found between overall satisfaction and satisfaction with the doctor, nursing, and general information.16,18 Additionally, overall satisfaction was correlated with the child’s impression of the nurse as friendly and the nurse and doctor as transmitting serenity.18 Pooled results demonstrate associations between satisfaction and continuity of care, provider interpersonal behavior, and the care team comforting the child, explaining what is going on in the surgical process, and answering questions. Dissatisfaction was related to higher parental education, longer surgical procedures, surgical complications, and parents feeling overwhelmed. Four studies17,21,26,27 used validated instruments to measure satisfaction. These instruments included the health care attitudes questionnaire, perceptions of procedures questionnaire, children’s hospital ambulatory surgery questionnaire, and pediatric perianesthesia questionnaire. Families of children with disabilities reported lower satisfaction than did families with children without disabilities.

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Table 2. Detailed Results of 11 Studies Evaluating the Preoperative Experience. Reference No.


Study Focus

Pertinent Findings



Multidimensional preoperative education program vs routine information provided at time of scheduling



Preoperative therapeutic play vs routine information provided at time of scheduling



Multidimensional preoperative education program vs routine information provided at time of scheduling



Preoperative educational program with preadmission visit and role-play vs conventional verbal information



Home preoperative preparation with video and book vs in-office video preparation



Preoperative visit with tour, role-play with toys, familiarization with equipment



 Children experienced increasing anxiety from arrival on the ward from PACU followed by a decrease in anxiety 24 hours postoperatively.  Parent anxiety was lower in the experimental group.  Parents in the control and experimental groups were equally satisfied.  Children and adults in intervention group had less anxiety preand postoperatively.  Children in the intervention group better emotional scores.  Parents in the intervention group had higher satisfaction scores.  There was less child anxiety in the program group than control.  Parents in the nonintervention group consistently reported higher anxiety.  There was a strong positive association between child and parent anxiety.  Parents were overall very satisfied in both groups.  Satisfaction was higher in program group in children and adults.  Preoperative program increased knowledge, and it alleviated fear, especially in younger children.  Parents in the program group expressed less negative emotions.  There was less preoperative anxiety and higher overall satisfaction with overall experience in children and caregivers in the preoperative program.  Those dissatisfied would have liked additional supplementary information.  The preadmission visit reduced both parent and child anxiety.  The most beneficial aspects were reduction of anxiety, preparation for surgery, and centering the experience on the child, making it less unknown.  No difference in knowledge or satisfaction.









Preoperative verbal counseling vs verbal counseling and handout vs verbal counseling and video Internet preoperative preparation program vs standard preadmission visit and tour Presurgical information leaflet vs verbal information Presurgical informative video vs verbal information Supplemental preoperative handout and website

 No difference in anxiety for parents or children but higher child knowledge and satisfaction.  No difference in anxiety or satisfaction.  Moderate correlation between knowledge, satisfaction, need for information, and anxiety.  No difference in composite satisfaction score.  Greater mean composite satisfaction score with video in mothers with a graduate degree.  Most (80%) prefer more information even if they find the information confusing.

Abbreviations: LOE, level of evidence; PACU, pediatric acute care unit.

Families of children with disabilities reported more negative comments in reference to the physician’s behavior, the information provided by the physician, and how the physician handled their anxiety.

Patient Experience in the Postoperative Setting Table 4 contains the summary of findings from the 3 studies evaluating the postoperative surgical experience. All

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Table 3. Detailed Results of 14 Studies Evaluating the Operative Experience. Reference No.


Study Focus

Pertinent Findings



Parental presence for induction of anesthesia



Parental presence for induction of general anesthesia



Perioperative experience of children with disabilities



Parent perspective of quality of outpatient surgical experience



Parent satisfaction with outpatient surgical experience



Quality of nurse practitioner preoperative evaluation



Impact of continuity of care on the perioperative experience





Interaction between health care providers, families, and children perioperatively Impact of nurse liaison program on perioperative experience



Child perspectives of the operative experience





Quality of care at ambulatory care center vs hospital Parental experience with same-day surgical evaluation and surgery





Parental experience in surgical fasttrack pathway Parent satisfaction with day case surgery

 No difference in anxiety or overall satisfaction, with overall high level of satisfaction.  Greatest satisfaction when given clear explanations and staff demonstrated care and concern.  No difference in mean parent anxiety and intensity of health care attitudes preand postoperatively.  No differences in satisfaction level between groups on any individual item.  Overall satisfaction levels lowest for admitting procedures but high for all other items.  Overall satisfaction lower for both groups than control.  Lowest satisfaction for amount of information provided.  Disability groups reported more negative comments with regard to the physician’s behavior, content of discussion with the physician, and how the physician handled their anxiety. Families with these negative experiences scored lower for general satisfaction.  Overall satisfaction and satisfaction with surgeon correlated with satisfaction with nursing, general information, and anesthesia.  Dissatisfaction was correlated by higher education of parent, longer surgical time, and complications with anesthesia.  Degree of satisfaction with nursing care associated with child’s impression of the nurse as friendly or reserved.  Overall satisfaction associated with child’s impression of the nurse and doctor.  Absence of fear associated with serenity transmitted by the nurse and doctor and absence of anxiety on the day before the operation.  Child anxiety most associated with a bad impression of the operating room.  Children most concerned with missing their parent, fear of unknown people, and fear of feeling pain.  Overall high satisfaction ratings with no difference between groups.  Positive remarks relating to staff’s ability to comfort the child, talk to the child, give thorough explanations, answer questions, and treat the child like family.  Child anxiety lower in those with continuity of care and communication.  Anxiety continuously decreased during the day in the continuity of care group but not in control.  Physicians engaged in larger mean proportions of medical talk with adults and more nonmedical talk with children.  High overall satisfaction.  Majority felt the nurse liaison was available to answer questions and helped reduce family anxiety.  Preoperatively, children are mainly concerned with having to endure an unknown, unpredictable, and distressful situation.  Intraoperatively, they feel they lose control.  Postoperatively, they feel relieved and a sense of accomplishment.  Patients generally had a positive experience at both sites.  Parents were overall very satisfied with the convenience, information given, ease of scheduling, and care received.  Most would recommend the service to a friend.  The majority of patients were very satisfied and would like fast-track care again.  Most were satisfied with the care received and would opt for day surgery again.  Dissatisfaction correlated with child vomiting on discharge, feeling rushed out of the hospital, and feeling overwhelmed with home childcare.

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Table 4. Detailed Results of 3 Studies Evaluating Patient Experience in the Postoperative Setting. Reference No.


Study Focus

Pertinent Findings



Parent satisfaction with telephone call for follow-up



Parent and patient experience with bedside surgical grand rounds



Child experience with hospital admission for surgery

 All were satisfied with the telephone call and felt it offered reassurance and the opportunity to ask questions.  Most parents felt the surgical grand round to be positive and educational and to answer their questions but also felt that it made their child anxious.  A third of teenagers felt anxious with the rounds, but the overall experience did not affect most.  The majority of young patients felt neutral about the experience.  Children experienced a fear and anxiety associated with loneliness, which was heightened in the immediate postoperative period.  The longer the child was in the hospital, the less he or she experienced these emotions.  They all reported they would not be as fearful if they were admitted to the hospital again.

Abbreviation: LOE, level of evidence.

were prospective cohort studies. No validated instruments were used to evaluate the postoperative care experience. One study evaluated the impact of a telephone call replacing postoperative visits following ambulatory general surgical procedures.30 All patients were very satisfied with both modes of follow-up and appreciated the opportunity to ask questions. A separate study investigated the impact of bedside surgical grand rounds on parents and for children admitted to the surgical inpatient unit.28 Most parents found the rounding experience positive but were concerned that the information presented caused their children anxiety. These parents felt that provider interactions with the children were most helpful in alleviating anxiety. The children felt neutral about the experience. Another study observed children admitted to the surgical ward.29 Through interviews, observations, and interpretations of drawings it was found that children experienced fear, anxiety, and loneliness when admitted to the hospital, but these feelings subsided the longer the child was in the hospital and became familiar with the providers and surroundings.

Patient Experience in the Outpatient Setting Table 5 summarizes the results of the 7 publications evaluating the outpatient care experience. The majority (n = 5) were observational studies, while 2 were cross-sectional analyses. Four authors used validated measurement tools, and the remaining 3 generated their own surveys to measure satisfaction. Pooled results from the studies indicate relationships between overall satisfaction and satisfaction with the provider, provider reliability, and access and convenience.9-13

Lower patient satisfaction scores were found when patients were younger children, when care was based within the academic setting, and when parents sought additional advice from sources other than the surgeon.8,12,13

Discussion This study examines the published literature over the last 20 years evaluating patient experience of care and patient satisfaction to improve processes and care quality in pediatric surgery. We found a diverse array of studies with only a few validated tools used to measure patient experience of care. Level of evidence was heterogeneous; however, only 12 were prospective cohort studies or randomized controlled trials. Overall, higher satisfaction was correlated with provision of information to the family and also with specific provider interpersonal behaviors. In 2001, the IOM emphasized the importance of patientcentered care in its report Crossing the Quality Chasm.1 Since then, patient experience of care and patient satisfaction have become increasingly popular topics of research and quality improvement. Patient satisfaction is a subjective measure influenced by many factors; however, it lacks a defined consensus in classification.42-43 Patient expectations are an important component of satisfaction and are influenced by diagnosis, setting, time, and knowledge.44 Therefore, patient satisfaction varies within specific clinical areas of care. Reports on patient experience of care within pediatric surgical subspecialty care are not plentiful and significantly lag behind studies about satisfaction in the primary care arena.45 We noted a significant increase in the number of publications evaluating patient experience of care as a process measure or quality indicator in pediatric surgery over the last 10

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Table 5. Detailed Results of 7 Studies Evaluating the Outpatient Experience. Reference No.


Study Focus

Pertinent Findings



Patient experience in outpatient clinics



Patient satisfaction in academic outpatient clinics



Patient and family satisfaction in outpatient clinics



Quality of care in outpatient clinics



Parent experience with tele-health





 Mean scores were lower for children overall and in all care domains except ‘‘care provider.’’  Adults were more likely to give top box scores overall and for all domains except ‘‘care provider.’’  Children in the youngest age group were less likely to report top box scores compared with older children.  Overall mean survey scores from the teaching setting were lower compared with the nonteaching setting.  In the teaching setting scores were lowest for ‘‘access to care’’ and ‘‘personal issues.’’  Scores were lowest for children in the youngest age group in the teaching setting.  Children in the teaching setting were less likely to have top box scores overall.  Overall patient satisfaction correlated with satisfaction with provider, wait time in the examination room, and wait time in the reception area.  Satisfaction with provider had largest influence over patient satisfaction.  Wait times in the reception area and in the examination room predicted overall satisfaction with the clinical encounter.  Overall satisfaction associated with access and convenience, doctor’s attention, reliability, and satisfaction with the staff.  Recommending clinic associated with reliability, doctor’s attention, assurance, and loyalty.  Likelihood of returning associated with access and convenience, reliability, doctor’s attention, and assurance.  Majority of parents indicated that tele-health made it easier to access health care services and saved them money and that they would use it again.  Patients who did not seek advice from other providers were more satisfied than those who did.  Satisfaction with the decision to have surgery was high.  Satisfaction with the physician and office visit was very good or excellent.  The strongest predictor of surgical cancellation was dissatisfaction with initial decision to undergo surgery.

Placebo response following outpatient clinic encounters Relationship between satisfaction with decision scale and patient compliance

Abbreviation: LOE, level of evidence.

years. This finding illustrates that patient satisfaction is indeed a valuable and powerful measure, rapidly gaining significance within the current health care climate due to the emphasis many organizations such as the IOM and AAP have placed on using patient experience to improve quality of care and also given the recent impetus for organizations and providers to publicly report satisfaction scores.46 The majority of the studies included used self-generated surveys with either rating scales or open-ended questions to measure parent or child satisfaction. None of the validated instruments used were specific to the pediatric surgical population. Therefore, it is difficult to draw aggregated conclusions from the results. A standardized tool to measure

satisfaction in the pediatric surgical population may assist in further research and quality improvement efforts in the pediatric surgical setting and make findings more generalizable. This effort has been accomplished in the primary care setting through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.47 Measuring patient experience is challenging in pediatric surgical care, as the encounter is multifaceted, involving parent and children. Processes that empower both appear to have the most impact on improving overall satisfaction. The aggregated results across all settings in this study demonstrate correlations between satisfaction and continuous family-directed information provided by the surgical team,

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as well as responsiveness and effective care provider interpersonal behaviors such as empathy, kindness, and compassion. These findings are consistent with those of many previous studies.45,47-49 Similarly, prior reports show that child anxiety decreases with more knowledge and familiarity with caregivers and occurrences.48,50 Surgeons have the opportunity to improve the quality of information given to families and the manner in which it is communicated. In doing so, they have a well-defined mode of increasing the satisfaction of their patients, as both information giving and positive provider interpersonal behaviors were consistently correlated with better family experiences. In the studies we evaluated, multidimensional preoperative educational programs that included facets such as role-play, hands-on familiarization with the operative process, and therapeutic play decreased anxiety and improved the experience, whereas informative videos, leaflets, and Internet programs did not make a substantial difference. In the operative setting, perception of the care team as knowledgeable and caring was correlated with higher satisfaction scores. Postoperative telephone calls and bedside rounds also related to high satisfaction scores. The results of our study should be interpreted with several limitations. First, we were only able to review published studies, thereby raising the possibility of publication bias. A study showing poor patient satisfaction may be less likely to be published than one showing high satisfaction. Second, we limited our search to English-language articles over the last 20 years. We believe these studies to be most germane given the relatively recent interest in patient experience of care. We included those studies written in English but published in other countries. As the medical systems and cultural expectations may differ from those in the United States, some of the findings may not be applicable to patients in the United States. Despite this, given the lack of research in this area, we felt it was important to include all of the studies. Third, the articles were highly heterogeneous with respect to the population evaluated, methods of measuring satisfaction, quality of study design, and results reported. Limited data precluded our ability to identify specific patient satisfaction improvement tools. Finally, our classification of the studies based on settings may not fully represent the spectrum of patient or parent experience measurement. A different grouping, such as more broad classification into hospital and outpatient settings, may have resulted in a different summary of findings compared to our present study. Health care quality as a concept is multifaceted and encompasses key pillars of efficiency, access, timeliness, effectiveness/patient outcomes, equity, and patient centeredness.1 The correlation between patient satisfaction, as a measure of patient-centeredness, and health outcomes is controversial, as the drivers of satisfaction are unclear. Prior studies have argued that patient satisfaction alone cannot determine the overall quality of surgical care,51 and in fact high patient satisfaction may correlate with increased morbidity and costlier care in some settings.52,53 Additional studies have questioned the usefulness of patient satisfaction as a

measure for patient outcomes as there is no standardized tool to evaluate it.54 Thus, it may be premature to actively use patient experience as a measure of health care quality, particularly in the pediatric surgical care setting. A survey instrument validated for use in the pediatric surgical care setting, including consideration for caregiver proxy responses and questions that pertain specifically to perioperative issues in pediatrics, would be more valuable to indicate patient- and family-centered culture and operative processes. The current literature suggests that parents highly value knowledge, information giving, and positive provider interpersonal behaviors. Children’s care experiences are improved by continuity and familiarity of care providers. A validated tool to measure both parent and child satisfaction in the pediatric surgical setting will improve quality of care by providing information specific to this unique population. Ultimately, this will strengthen the pediatric surgical experience to best serve the child and family.

Conclusion Experience of care or patient satisfaction is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Current studies on patient satisfaction are heterogeneous, and many use nonvalidated measurement tools. Development of validated instruments to measure both the parent’s and child’s experience in the surgical setting may direct initiatives for improvement in quality of care and assist in future research in this discipline. This review emphasizes that providing families with information during each stage of the surgical process improves the patient experience and satisfaction. These findings bear significance as patient experience measures become routinely integrated with policies and processes in pediatric otolaryngology and surgery. Author Contributions Alexandra G. Espinel, conception and design, data acquisition, analysis and interpretation, article draft and revision, approval of manuscript; Rahul K. Shah, conception and design, data analysis and interpretation, article revision, approval of manuscript; Michael E. McCormick, analysis and interpretation of data, article revision, approval of manuscript; Paul R. Krakovitz, analysis and interpretation of data, article revision, approval of manuscript; Emily F. Boss, conception and design, data analysis and interpretation, article revision, approval of manuscript.

Disclosures Competing interests: None. Sponsorships: None. Funding source: Emily F. Boss was sponsored by the Johns Hopkins Clinician Scientist Award.

References 1. Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

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Otolaryngology–Head and Neck Surgery 150(5)

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Patient satisfaction in pediatric surgical care: a systematic review.

This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care...
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