Safety and Satisfaction:
Where are the Connections?

By Robert J. Wolosin, PhD

Patient safety and patient satisfaction should go hand-in-hand. Hospitals ought to be able to provide care that is safe and meets or exceeds patient expectations for service quality. Similar practices (e.g., open communication among staff members) and values (e.g., patient- and family-centered care) contribute both to safety and satisfaction. Nurses who are themselves satisfied and engaged, and who can spend sufficient time at the bedside, should know their patients better, learn their patients' vulnerabilities, and have the time and energy to ward off potential harms. At the same time, such nurses are in a better position to address patients' and families' psychosocial needs — a consistently powerful driver of patient satisfaction (Donabedian, 1988; Gerteis, Edgman-Levitan, Daley & Delbanco, 1993; Press 2005).

Recently published literature offers hints about connections between patient safety and patient satisfaction. To review it briefly:

• In October 2005, the Joint Commission's Journal on Quality and Patient Safety published a series of case studies of healthcare institutions' efforts to improve both quality and safety. One of these was from Lehigh Valley Hospital in Allentown, Pennsylvania, which used active engagement of patients and families in attempting to improve patient safety (Anthony, Ritter, Davis, Hitchings, Capuano, & Mawji, 2005).
  
  
• Blegen, in the 2006 Annual Review of Nursing Research, cited several earlier works that investigated both safety and satisfaction as they respond to levels of nurse staffing (Blegen, 2006).
  
  
• Weingart and colleagues (2006) examined inpatients' reports of service "incidents" — deficiencies in service quality such as waits/delays, poor communication, poor care coordination, lack of respect for personal preferences, or environmental issues. They found that roughly 40% of patients reported at least one incident and that reporting of incidents was associated with diminished patient satisfaction. Although the authors did not tie their results to adverse events that happened to the same patients, it does not require much imagination to link service deficiencies such as poor care coordination and poor communication, to an increased risk of suffering an adverse event.
  
  
• Meade, Bursell, and Ketelsen (2006) conducted a quasi-experimental study of the effects of a specific nursing practice on patient falls and patient satisfaction. Nurses rounded on their patients either at 1- or 2-hour intervals; they used a standard protocol that included multiple actions (e.g., assessment of pain, offering toileting assistance, assessment of need to reposition the patient). The authors found a significant reduction in patient falls for hourly rounding and a significant increase in patient satisfaction for both intervals. Although it was not a true experiment with random assignment of units to conditions, the study nonetheless offers evidence that safety (as indexed by patient falls) and satisfaction respond similarly to enhanced nursing activities.
  
  
• Weingart's group reported on oncology patients' perceptions of adverse events during outpatient treatment. Patients tended to classify service quality incidents as adverse events, even when they understood the constituents of safe practice (Weingart et al., 2007). Thus, patients associate safety and quality.
  
  
• Wong and Cummings (2007) reviewed seven quantitative studies of the relationship between nursing leadership and patient outcomes. They found significant associations between positive leadership behaviors and both increased patient satisfaction and reduced adverse events.
  
  
• Williams, Manwell, Konrad, and Linzer (2007) examined the physician side of the quality equation. Physicians in ambulatory clinics in the upper Midwest and New York City were asked to rate their practice's culture along several dimensions, as well as their own job satisfaction, level of burnout, provision of suboptimal care, and the likelihood of making errors in the future. They found that a practice culture that emphasizes quality decreases physician estimates of both their likelihood of making errors and their delivery of suboptimal patient care, including failure to meet patient needs for information — an important driver of patient satisfaction.
  
  
• Kaldenberg and Trucano (2007) examined facility-level relationships between hospital-acquired infection (HAI) rates and patient perceptions of specific aspects of hospital quality in the State of Pennsylvania. Specifically, they chose three questions from an inpatient survey thought to measure practices that, when poorly executed, could create a more infection-prone environment: ratings of cleanliness; of the skill of the person who took the patient's blood; and of nurses' response to the call button. All three were found to be significantly, negatively correlated with HAI rates
  
  
• A direct examination of the correlation between overall inpatient satisfaction scores and overall employee ratings of patient safety from the same set of hospitals found a substantial relationship (Wolosin, 2007).

Thus, there is evidence that patient safety and patient satisfaction are linked. At this time, however, little is known about specific features of a hospital's culture associated with this link. This article explores the basis of the safety-satisfaction link by analyzing data from surveys of patients and employees from the same hospitals.

Survey Instruments
Two survey instruments were used. The Press Ganey Inpatient Survey, initially developed in 1987 and revalidated in 2002 and 2007, is structured around a typical hospital visit, starting with admission. It inquires about important hospital events, processes, people, and how well the patient's psychosocial needs were addressed. The survey has been described more completely elsewhere (Gesell, Clark et al., 2005; Kaldenberg, Mylod, & Drain, 2003).

Press Ganey's Safety Culture Survey was adapted from a public-domain instrument developed by the Agency for Healthcare Research and Quality (AHRQ) in 2004. It assesses hospital's culture of safety by inquiring into the individual/group values, attitudes, perceptions, and patterns of behavior of the staff. Psychometric properties of the original AHRQ survey tool can be found in Sorra and Nieva, 2004; those of the adapted instrument are available from the author.

The Safety Culture Survey is based on the premise that the safety of patients depends heavily on employee practices within hospital units. These include open communication across staff levels, teamwork within and between units, a non-punitive response to errors, and the ability to learn from errors. In addition, respondents are asked to estimate how frequently various types of mistakes are made and the number of event reports they submit, and to grade their unit's safety on a scale from Excellent to Failing.

Table 1 summarizes the salient characteristics of the instruments.

Table 1: Instrument Characteristics

CHARACTERISTIC	INPATIENT SURVEY		SAFETY CULTURE SURVEY
Year developed	1987		2004
Most recent validation	2002		2007
What is measured	Patient evaluations of service quality		Employee opinions about safety practices
Response scale type	Quality		Agreement; Frequency; "Grade"
Response scale points	5		5 (Agreement and "Grade"); 5 and 6 (Frequency)
Cronbach Alpha	0.98		0.95
Distribution method	Mail out, mail back		Hand out, hand back
Inclusion criteria	Discharged adult patients		Facility employees
Number of ratings	38		46
Number of subscales	10		13
SUBSCALES	NAME	NUMBER OF ITEMS	NAME	NUMBER OF ITEMS
	Admission	2	Teamwork within units	4
	Room	5	Supervisor/ Manager Expectations/ Actions	4
	Meals	3	Management Support	3
	Nurses	6	Organizational Learning	3
	Tests and Treatments	4	Overall Safety Perceptions	4
	Visitors and Family	2	Feedback/ Communication about Error	3
	Physician	5	Communication Openness	3
	Discharge	3	Frequency of Reports	3
	Personal issues	5	Teamwork across units	4
	Overall Assessment	3	Staffing	4
			Handoffs/ Transitions	4
			Nonpunitive Response	3
			Overall Ratings	4

Results
As of this writing, 44 Press Ganey clients used both instruments. Surveys from those clients returned between October 2006 and August 2007 were analyzed. Together, they represent ratings of 53,784 patients and 20,057 hospital personnel.

There are 46 items rated on the Safety Culture Survey, and 38 on the patient satisfaction survey, yielding 1,748 item-level intercorrelations. The matrix representing these correlations was examined to find items from one of the surveys most related to items from the other. Two criteria of relatedness were used: (1) an average correlation of r = .40 or more between an item from one of the surveys and all the items from the other, and (2) correlated .40 or higher with a large percentage of the items on the other survey.

The results are shown in Tables 2 and 3.

Table 2: Safety Culture Survey Items' Relationship with Inpatient Survey (IS) Items

Safety Culture Survey Item	Safety Culture Survey subscale	Average correlation with IS Items	Percent of possible IS items correlated at least .40
It is just by chance that more serious mistakes don't happen around here.	Overall perceptions	.43	61%
We have patient safety problems in this unit.	Overall perceptions	.46	68%
We work in "crisis mode" trying to do too much, too quickly.	Staffing	.46	66%
Staff in this unit work longer hours than is best for patient care.	Staffing	.49	74%
Things "fall between the cracks" when transferring patients from one unit to another.	Handoffs/ Transitions	.43	63%
Important patient care information is often lost during shift changes.	Handoffs/ Transitions	.40	53%
Problems often occur in the exchange of information across hospital units.	Handoffs/ Transitions	.49	76%
Shift changes are problematic for patients in this hospital.	Handoffs/ Transitions	.47	66%
Staff feel like their mistakes are held against them.	Nonpunitive response	.40	61%
When an event is reported, it feels like the person is being written up, not the problem.	Nonpunitive response	.41	63%
Staff worry that mistakes they make are kept in their personnel file.	Nonpunitive response	.47	82%
I would feel safe being treated as a patient here.	Overall ratings	.50	71%

Table 3: Inpatient Survey Items' Relationship with Safety Culture Survey (SCS) Items

Inpatient Survey Item	Inpatient Survey subscale	Average correlation with SCS Items	Percent of possible SCS items correlated greater than .40
Speed of admission process	Admission	.49	78%
Pleasantness of room décor	Room	.44	70%
Noise level in and around room	Room	.52	96%
Room cleanliness	Room	.40	52%
Courtesy of the person who served your food	Meals	.46	72%
Promptness in responding to call light	Nurses	.44	65%
Accommodations and comfort for visitors	Visitors and Family	.48	80%
Staff attitude toward your visitors	Visitors and Family	.40	43%
Speed of discharge process after you were told you could go home	Discharge	.45	61%
Extent to which you felt ready to be discharged	Discharge	.41	52%
Response to concerns and complaints made during your stay	Personal Issues	.41	54%

Table 2 shows the 12 Safety Culture Survey items that met the criteria, the subscale of the Safety Culture Survey which they represent, their average correlation with inpatient items, and the percentage of the inpatient items for which the item correlated r = .40 or higher. Table 3 shows analogous information for the 11 items from the Inpatient Survey that met the same criteria.

Table 2 shows that several separate facets of safety culture, including global ratings, staffing, handoffs/transitions, and a nonpunitive response to error, were substantially related to patients' evaluations of their hospital experiences. Employee opinions represented by these questions were highly related to patient evaluations of their care. The item, "Staff worry that mistakes they make are kept in their personnel file," met criteria for 82% of Inpatient Survey items.

Table 3 shows a variety of patient experiences, including experiences with processes (admission and discharge), physical comforts (room, meals), staff (nurses), treatment of visitors (visitors and family), and concern for person (personal issues) were related to employee opinions about the hospital's culture of safety. The item, "Noise level in and around the room," met criteria for nearly all Safety Culture Survey items.

Comment
As customers of hospital services, patients and employees encounter any particular hospital from differing standpoints. Nonetheless, employees and patients each have a privileged position from which to report on the interface between the care processes that bring them together and the structure of the institution: Employees have first-hand knowledge about the safety practices they use and see around them; patients have first-hand knowledge of their experiences. As shown in Tables 2 and 3, there are strong relationships between employee perceptions of patient safety, on the one hand, and patient satisfaction, on the other.

Safety Culture Survey items that related strongly with Inpatient Survey items had to do with staffing, handoffs/transitions, and an atmosphere of blame.

• Staffing. Hospitals rated by employees as having adequate staffing levels generate high degrees of patient satisfaction. This finding accords well with literature that emphasizes the importance of nurse staffing levels and workload for care quality (e.g., Chapter 10, "Nursing," in Griffith and White, 2002 ; Kurtzman and Corrigan, 2007), and for patient safety (e.g., Blegen, 2006; Wachter & Shojania, 2004). .
  
  
• Handoffs/transitions. Proper communication of clinical information has been noted frequently as critical for patient safety (Kohn, Corrigan, & Donaldson, 2000; Landro, 2006; Leonard, Graham, & Bonacum, 2004; National Quality Forum, 2003; Wachter & Shojania, 2004). In the current study, hospitals rated as having good practices for transferring patient information from one shift or unit to another are hospitals with high levels of patient satisfaction, as well.
  
  
• Nonpunitive response to error. Safety experts (e.g., Leape, 1994; Wachter & Shojania, 2004) have noted that an atmosphere of punishment and blame for errors makes for low levels of patient safety. This study found an association between an atmosphere of blame and lower levels of patient satisfaction, as well.

Table 3 indicates that Inpatient Survey items that showed a strong relationship with scores on the Safety Culture Survey represent several aspects of patient satisfaction.

• Patients' ratings of the hospital's treatment of visitors strongly predicted employee opinions about safety. Attention to visitors' needs is a service extra; hospitals that understand the importance of visitors to the patient's overall well-being and take steps to make visitors welcome, also promote safe practices.
  
  
• Satisfaction with admission and discharge processes was highly related to safety ratings. Admission to and especially discharge from a hospital are indications of the facility's efficiency; a patient's discharge requires the coordination of numerous personnel and departments. Hospitals that handle these transitions well may be more patient-centered or more efficient in general, thus more likely to pay attention to patient safety.
  
  
• Patient ratings of noise levels in and around their room were substantially related to safety culture ratings. In 1992, Bitner pointed out the importance of the overall "Servicescape" for customers and employees. Her list of important "ambient conditions" within the service domain (such as a hospital ward) included temperature, air quality, and, notably, noise. Interfering and distracting sounds may contribute directly to medical and nursing errors in that noisy environments can make it difficult for healthcare personnel to communicate accurately (Tijunelis et al., 2005; Joseph & Ulrich, 2007). Or, it can result from unsafe practice, as when a tumultuous scene follows the discovery of an adverse event, or from the activation of warning devices. Noise directly interferes with care quality, causing sleep deprivation, disturbance, and anxiety. It decreases patient confidence in clinical abilities of the staff, and contributes to patient falls, decreased wound healing, sleep deprivation and other undesired outcomes (Christensen, 2005; Mazer, 2005). In ICU's, even run-of-the-mill noise levels have been found to be exceedingly high and to interfere with patients' sleep and healing (Kahn, Cook, Carlisle, Nelson, Kramer, & Millman, 1998). In addition, noise contributes to worker exhaustion, burnout, depression, and irritability — increasing the chances for error.

Summary
There are specific links between patients' evaluations of service quality in a healthcare facility and employees' opinions about the safety culture of that facility. From the perspective of employees, these links pertain to adequate staff levels, good communication practices that minimize "dropping the ball," and an atmosphere that recognizes the systemic nature of error. From the perspective of patients, the links have to do with organizational efficiency at entry and exit, service extras for family/visitors, and a tranquil, quiet atmosphere that promotes healing.

The design of this study cannot determine causality. Indeed, safety and satisfaction are likely linked because both are manifestations of an underlying hospital culture that is committed to patient welfare and a hospital administration that takes steps to meet or exceed patient expectations while promoting error-free care. Nonetheless, it seems reasonable to hypothesize that steps taken to improve, e.g., a hospital patient safety practice, will ultimately result in improvements in patient satisfaction.

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