Patient Experience during Hospital Stay : A Pilot Survey

Introduction: Hospital inpatient care is provided to individuals who have a condition that requires them to stay in hospital. Patient experience is an important aspect of high-quality patient-centered care. Aim: With this pilot survey we aimed to obtain patient feedback on their experiences during their hospital stay, highlight areas of best practice and areas for improvement and provide a basis for a hospital-wide inpatient experience survey. Patients and Methods: Anonymous patient experience questionnaires were given to patients who were discharged from hospital during the month of May 2016. Patients were asked to answer 45 questions concerning their experience during hospital stay using the five-point Likert scale, and hand back the questionnaire before leaving the hospital. A suggestion box was provided for comments and suggestions for improvement. Results: Fifty-six questionnaires were handed out and 50 (from 27 males, 17 females and 6 patients who did not specify their gender) questionnaires were returned (89% response rate). Most of the responses fell within the “agree” to “strongly agree” range indicating a positive patient experience for most of the items addressed. Patients also provided useful comments and suggestions. Conclusion: Results of this survey indicate that patients generally had a positive experience during their hospital stay. This survey has revealed areas for improvement, and highlights the importance of patient experience when assessing a patient-centered service.


Inpatient care
Hospital inpatient care is provided for all individuals who have a condition that re-How to cite this paper: Sagi, S.V., Chen, C., Htun, K.Z., Puvanendrampillai, K., Ratnayake, M., Ngwira, J., Rajkanna, J. and Oyibo, S.O.(2016) Patient Experience during quires them to stay in hospital over one night or more.An admission to hospital could be as an emergency or as a planned admission.Health care statistics indicate that there were 15.9 million admissions to NHS hospitals in England in 2014/2015 and that this has increased compared to previous years [1].A stay in hospital overnight can be a daunting experience for a patient and their relatives, especially if accompanied by a negative experience.Patients deserve a positive/good experience during inpatient care from the point of admission to the hospital to the point of discharge and a smooth transition to post-discharge or outpatient care.

Importance of patient experience
Patient experience is an important aspect of high-quality care and healthcare providers must understand how their inpatients are experiencing care if we are to effectively translate patient needs and preferences into higher quality, safer and more efficient inpatient services [2].Patient satisfaction is another indicator of quality of care during hospital stay and is sometimes used synonymously with patient experience.Previous studies have highlighted important differences and discrepancies between patient experience and patient satisfaction [3].There have been several debates concerning methodological issues around measurement and interpretation of patient experience, but when care coordination and patient engagement are at the centre of improving patient experience and outcomes, valuable information can be obtained from these surveys to facilitate quality improvement [4].The results from patient experience measurements offer us the chance to improve care, meet patients' expectations and monitor healthcare performance through the eyes of the patient [5] [6].

Aim
The aims of this pilot survey were to obtain patient feedback on their experiences during their hospital stay, to highlight areas of best practice and areas for improvement and provide a basis for a hospital-wide inpatient experience survey.

Inpatient care pathway
Patients are admitted through the emergency department or directly to the medical assessment unit.If after initial management they require further medical investigations and treatment they are transferred to the medical ward for continuation of care before discharge.Therefore, patient care can be divided into several sections depending on their care pathway; however this survey concentrates on patient experience during care on the medical ward, which is just before discharge from hospital for most patients.

Sample population
The sample population consisted of patients who had received care on our medical ward and were being discharged during the month of May 2016.Day-case patients (patients who arrived and left the hospital the same day), patients who were incapable of filling in the questionnaire due to impaired cognitive function and patients who refused to participate were excluded from the survey.

Questionnaires and administration
The Patient Experience Questionnaire (PEQ) was adopted from that used for the Scottish inpatient patient experience postal survey [7].The questionnaire consisted of 45 questions that we fashioned around five domains applicable to patient experience of care on our medical ward.The five domains used to assess patient experience were: ward facilities, medical doctors, other members of the multidisciplinary team, communication with relatives and discharge planning.Each question required one of five answers using the 5-point Likert scale (strongly agree, agree, neither agree or disagree, disagree, strongly disagree) and additional tick boxes for "does not apply" and "don't know" if necessary.There was also a section for comments/suggestions.
The PEQs were given to patients on the morning of their planned discharge.The PEQ had no patient identifiable details, were completely anonymized and were given to patients by the ward clerks as independent helpers.The time frame for the collection of the returned questionnaires was by the time the patient left the medical ward.
This patient experience survey was registered with our Quality, Governance and Compliance Department as a quality improvement project and therefore, ethical approval was not required before commencement.

Data analysis
The data obtained from this survey was analyzed both qualitatively and quantitatively.To be able to compare responses to various questions through graphical representation, the response-options on the 5-point Likert scale above were given weighting scores (1.0, 0.75, 0.5, 0.25, and 0, respectively).For each question the number of respondents who selected a response-option was multiplied by the weighting score assigned to that response-option.The sum total for all response-options produced a summative Likert score for that question.The summative Likert score was then divided by the total number of respondents to that question to produce an Agreement Score (weighted average ranging from "1" meaning that respondents strongly agree to that question down to "0" meaning that the respondents strongly disagree to that question) [8] [9] [10].The scoring system was reversed for negative questions.

Sample description
During the month of May 2016 our medical ward had a total of 80 discharges but 56 inpatients were given a copy of the questionnaire (PEQ) to be completed before leaving the hospital.Of the 24 patients that were excluded, 4 were day cases, 6 patients were not interested and the other 14 patients had impaired cognitive function and would not have been able to complete the questionnaire.Fifty patients completed the PEQ and handed them in before leaving the hospital (89% response rate).The group consisted of 27 males, 17 females (and 6 patients who did not specify their gender).The group had an average age of 73 years (range: 25 -96).

Response to questions
Fifty PEQs were analyzed.Table 1 shows the questions relating to patient experience with ward facilities such as rooms, meals, noise disturbance general assistance from staff.Patients had a good (positive) experience with most of the items, however, a significant number were less happy with noise disturbance from other patients and staff, being threatened or bothered by other patients, and general assistance from staff in a reasonable time.Table 2 shows the questions relating to patient experience with the medical doctors attending to them.Patients generally had a positive experience with most of the items but a significant number of patients were less happy with the fact that some doctors talked about them, in front of them, as if the patient was not there.Table 3 shows the questions relating to patient experience with other members of the multidisciplinary team such as general and specialist nurses, physiotherapists, occupational therapists and healthcare assistants.Patents generally had a positive experience with most of the items but several patients were less happy with the response to the "call bell" in good time.Table 4 shows questions relating to information being passed on to patients' relatives appropriately.Patients generally had a positive experience with most of the items in this domain.Table 5 shows the questions relating to patient experience with discharge planning.Patients generally had a positive experience with most of the items but some patients felt that they were not given enough information concerning danger signs to watch out for on leaving the hospital.
Figure 1 shows a graphical representation of the agreement scores (weighted averages of the Likert scores) for each question in ascending order.This demonstrates a median (inter-quartile range) for all scores of 0.787 (0.732 -0.811), indicating that most of the responses to the questions fell within the "agree" to "strongly agree" range.We chose the lower quartile to represent those areas in need of urgent attention and improvement, while the upper quartile represented those areas in which we were doing exceptionally well.

Lower quartile
The lowest quartile comprised of the first 11 questions that had a score below 0.732 highlighting that these needed urgent attention.These questions related to patient experience of self-involvement with care and discharge planning, staff assistance within reasonable time, disturbance from staff and other patients, doctors conversing as if the patient was invisible, inadequate discussion about discharge medications (side-effects, uses, etc.) and discussion around danger signs to look out for on leaving the hospital.

Upper quartile
The upper quartile (scores more than 0.811) comprised of the last 11 questions relating to: attendance to hygiene needs, trust and confidence in both the nurses and doctors attending to them, satisfaction with drinks, rooms, adequacy and cleanliness of bathroom facilities, relative being aware of how to contact/visit and relatives being appropriately informed of their care.
Figure 1.Graphical representation of agreement scores (weighted averages) for each question in ascending order.X-axis = list of questions; Y-axis = weighted average score on the Likert scale for each question (1 = strongly agree, 0.75 = agree, 0.5 = neither agree or disagree, 0.25 = disagree, 0 = strongly disagree).The first two questions had the weighting system reversed so that low scores meant poor experience with noise from other patients/staff and doctors talking in front of them as if they were invisible.

Qualitative responses
Twenty-six responders made useful comments and further suggestions for improvement to improve the experience during hospital stay.Twenty-one (80%) of these comments indicated a positive patient experience, while the other five comments indicated areas for improvement.These comments and suggestions are shown in Figure 2.

Discussion
A positive patient experience is of paramount importance when delivering a patientcentered service.We assessed patient experience during hospital stay on our medical ward using a patient experience questionnaire.Results of this survey indicate that patients generally had a positive experience during their hospital stay.

Implications to our service
The results of this survey have provided us with valuable quantitative and qualitative information, which will help us to improve our service in relation to patients needs and thereby enhance patient experience on a medical ward.Firstly, this survey demonstrated that patients felt that they were not getting staff assistance within a reasonable time.This is an ongoing issue with increasing workload and limited resources but this is  Thirdly, some patients felt they did not get enough information about the medications they were leaving the hospital with (e.g., side-effects, what the medications were for, etc.) and danger signs to watch out for.With the joint collaboration of the nurses, doctors and pharmacist we are making improvements with this issue.Fourthly, patients wanted to be more involved with their discharge planning and know who to contact concerning questions about their discharge.

Positive patient experience
Results from our surveys demonstrate that most patients generally had a positive experience during their hospital stay on our medical ward.Hospital stay for patients can range just a few days to a few weeks.On induction hospital staff are reminded that excellent patient care and a positive experience is the goal that should be strived for all patients and at all times.Patient feedback is essential to making continued improvements.

Previous studies in this field
There has been several national patient inpatient experience surveys employing postal questionnaires sent after the patient has left the hospital.The Scottish Inpatient Patient Experience Survey had a 48% response rate and assessed patient experience of care from admission to the emergency department and experience of the hospital and ward environment.Patients were most positive about environmental cleanliness, visiting hours and staff hand-washing, however they were markedly less positive about meals, nocturnal noise, knowing which nurse was in charge of the ward and discharge arrangements [7].The National Health Service Inpatient Survey had a 47% response rate and assessed patient experience of care from admission to discharge.Results were similar to that of the Scottish survey [2].Our survey may have revealed similar, recurring themes that have been found during previous national surveys, however we uniquely assessed patient experience specifically during care on a medical ward by use of questionnaires given to patients and returned before they left the hospital.The response rate for our survey is also higher than that for the national postal surveys.

Study limitations
This study has its limitations.Firstly, there was a response rate of 89% for those given PEQ, which is still significantly better than that reported in other mail surveys [11] [12] [13].However, due to the exclusion criteria, 24 patients were not given the PEQ and a further 6 patients did not return the PEQ.Therefore, our sample size represents 63% of the total number of patients discharged in that month.Secondly, we did not give the PEQ to patients with impaired cognitive function (e.g.dementia, mental health problems, etc.).As these patients were not represented in this survey there is the potential for exclusion bias.This important aspect needs to be addressed in future surveys because patients with mental health problems often have physical and mental health needs that go unrecognized [2].The experience of patients' family members could be another way of obtaining patient experience for this under-represented group of patients.Thirdly, the fact that the PEQ was hand distributed to be returned prior to leaving the hospital could be an imposition or a rush for some patients as opposed to postdischarge postal PEQs.However, the response rate was much higher than that for postal surveys and patient recollection of events may even be better.Further randomized controlled surveys are needed to compare these two methods.Fourthly, we did not collect or control for data concerning patient sociodemographic, clinical characteristics, and length of hospital stay: a larger study is required to assess the effect of these parameters on patient experience.Lastly we excluded patients that attended and left the ward the same day.A larger study is required so that we can compare the experience between patients who were on the ward for a period of time and patients who left the same day.

Conclusion
This inpatient patient experience survey has demonstrated that patients generally had a positive experience during their hospital stay.This survey has also demonstrated areas for improvement on the wards, which should be the aim when using patient experience surveys to assess patient-centered care.We hope to repeat this patient experience survey on more wards after one year.

Figure 2 .
Figure 2. Comments and suggestions made by responders concerning their experience during hospital stay.

Table 1 .
Questions concerning experience with ward facilities with results in whole numbers.

Table 2 .
Questions concerning experience with medical doctors with results in whole numbers.

Table 3 .
Questions concerning experience with other members of the multidisciplinary team with results in whole numbers.
Q12.I felt comfortable with the diabetic nurse(s) looking after me during the admission

Table 4 .
Questions concerning experience with healthcare communication with patients' relatives with results in whole numbers.

Table 5 .
Questions concerning experience with discharge planning with results in whole numbers.