Zishan K. Siddiqui, MD

We thank Mr. Zilm and colleagues for their interest in our work.[1] Certainly, we did not intend to imply that well‐designed buildings have little value in the efficient and patient‐centered delivery of healthcare. Our main goal was to highlight (1) that patients can distinguish between facility features and actual care delivery, and poor facilities alone should not be an excuse for poor patient satisfaction; and (2) that global evaluations are more dependent on perceived quality of care than on facility features. Furthermore, we agree with many of the points raised. Certainly, patient satisfaction is but 1 measure of successful facility design, and the delivery of modern healthcare requires updated facilities. However, based on our results, we think that healthcare administrators and designers should consider the return on investment on the costly features that are incorporated purely to improve patient satisfaction rather than for safety and staff effectiveness.

Referral patterns and patient expectations are likely very different for a tertiary care hospital like ours. A different relationship between facility design and patient satisfaction may indeed exist for community hospitals. However, we would caution against making this assumption without supportive evidence. Furthermore, it is difficult to attribute lack of improvement of physician scores in our study because of a ceiling effect. The baseline scores were certainly not exemplary, and there was plenty of room for improvement.

We agree that there is a need for high‐quality research to better understand the broader impact of healthcare design on meaningful outcomes. However, we are not impressed with the quality of much of the existing research tying physical facilities with patient stress or shorter length of stay, as mentioned by Mr. Zilm and colleagues. Evidence supporting investment in expensive facilities should be evaluated with the same high standards and rigor as for other healthcare decisions.

We thank Mr. Zilm and colleagues for their interest in our work.[1] Certainly, we did not intend to imply that well‐designed buildings have little value in the efficient and patient‐centered delivery of healthcare. Our main goal was to highlight (1) that patients can distinguish between facility features and actual care delivery, and poor facilities alone should not be an excuse for poor patient satisfaction; and (2) that global evaluations are more dependent on perceived quality of care than on facility features. Furthermore, we agree with many of the points raised. Certainly, patient satisfaction is but 1 measure of successful facility design, and the delivery of modern healthcare requires updated facilities. However, based on our results, we think that healthcare administrators and designers should consider the return on investment on the costly features that are incorporated purely to improve patient satisfaction rather than for safety and staff effectiveness.

Referral patterns and patient expectations are likely very different for a tertiary care hospital like ours. A different relationship between facility design and patient satisfaction may indeed exist for community hospitals. However, we would caution against making this assumption without supportive evidence. Furthermore, it is difficult to attribute lack of improvement of physician scores in our study because of a ceiling effect. The baseline scores were certainly not exemplary, and there was plenty of room for improvement.

We agree that there is a need for high‐quality research to better understand the broader impact of healthcare design on meaningful outcomes. However, we are not impressed with the quality of much of the existing research tying physical facilities with patient stress or shorter length of stay, as mentioned by Mr. Zilm and colleagues. Evidence supporting investment in expensive facilities should be evaluated with the same high standards and rigor as for other healthcare decisions.

We thank Mr. Zilm and colleagues for their interest in our work.[1] Certainly, we did not intend to imply that well‐designed buildings have little value in the efficient and patient‐centered delivery of healthcare. Our main goal was to highlight (1) that patients can distinguish between facility features and actual care delivery, and poor facilities alone should not be an excuse for poor patient satisfaction; and (2) that global evaluations are more dependent on perceived quality of care than on facility features. Furthermore, we agree with many of the points raised. Certainly, patient satisfaction is but 1 measure of successful facility design, and the delivery of modern healthcare requires updated facilities. However, based on our results, we think that healthcare administrators and designers should consider the return on investment on the costly features that are incorporated purely to improve patient satisfaction rather than for safety and staff effectiveness.

Referral patterns and patient expectations are likely very different for a tertiary care hospital like ours. A different relationship between facility design and patient satisfaction may indeed exist for community hospitals. However, we would caution against making this assumption without supportive evidence. Furthermore, it is difficult to attribute lack of improvement of physician scores in our study because of a ceiling effect. The baseline scores were certainly not exemplary, and there was plenty of room for improvement.

We agree that there is a need for high‐quality research to better understand the broader impact of healthcare design on meaningful outcomes. However, we are not impressed with the quality of much of the existing research tying physical facilities with patient stress or shorter length of stay, as mentioned by Mr. Zilm and colleagues. Evidence supporting investment in expensive facilities should be evaluated with the same high standards and rigor as for other healthcare decisions.

Hospitals are expensive and complex facilities to build and renovate. It is estimated $200 billion is being spent in the United States during this decade on hospital construction and renovation, and further expenditures in this area are expected.[1] Aging hospital infrastructure, competition, and health system expansion have motivated institutions to invest in renovation and new hospital building construction.[2, 3, 4, 5, 6, 7] There is a trend toward patient‐centered design in new hospital construction. Features of this trend include same‐handed design (ie, rooms on a unit have all beds oriented in the same direction and do not share headwalls); use of sound absorbent materials to reduced ambient noise[7, 8, 9]; rooms with improved view and increased natural lighting to reduce anxiety, decrease delirium, and increase sense of wellbeing[10, 11, 12]; incorporation of natural elements like gardens, water features, and art[12, 13, 14, 15, 16, 17, 18]; single‐patient rooms to reduce transmission of infection and enhance privacy and visitor comfort[7, 19, 20]; presence of comfortable waiting rooms and visitor accommodations to enhance comfort and family participation[21, 22, 23]; and hotel‐like amenities such as on‐demand entertainment and room service menus.[24, 25]

There is a belief among some hospital leaders that patients are generally unable to distinguish their positive experience with a pleasing healthcare environment from their positive experience with care, and thus improving facilities will lead to improved satisfaction across the board.[26, 27] In a controlled study of hospitalized patients, appealing rooms were associated with increased satisfaction with services including housekeeping and food service staff, meals, as well as physicians and overall satisfaction.[26] A 2012 survey of hospital leadership found that expanding and renovating facilities was considered a top priority in improving patient satisfaction, with 82% of the respondents stating that this was important.[27]

Despite these attitudes, the impact of patient‐centered design on patient satisfaction is not well understood. Studies have shown that renovations and hospital construction that incorporates noise reduction strategies, positive distraction, patient and caregiver control, attractive waiting rooms, improved patient room appearance, private rooms, and large windows result in improved satisfaction with nursing, noise level, unit environment and cleanliness, perceived wait time, discharge preparedness, and overall care. [7, 19, 20, 23, 28] However, these studies were limited by small sample size, inclusion of a narrow group of patients (eg, ambulatory, obstetric, geriatric rehabilitation, intensive care unit), and concurrent use of interventions other than design improvement (eg, nurse and patient education). Many of these studies did not use the ubiquitous Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient satisfaction surveys.

We sought to determine the changes in patient satisfaction that occurred during a natural experiment, in which clinical units (comprising stable nursing, physician, and unit teams) were relocated from an historic clinical building to a new clinical building that featured patient‐centered design, using HCAHPS and Press Ganey surveys and a large study population. We hypothesized that new building features would positively impact both facility related (eg, noise level), nonfacility related (eg, physician and housekeeping service related), and overall satisfaction.

METHODS

This was a retrospective analysis of prospectively collected Press Ganey and HCAPHS patient satisfaction survey data for a single academic tertiary care hospital.[29] The research project was reviewed and approved by the institutional review board.

Statistical Analysis

Percent top‐box scores were calculated for each survey item as the percent of patients who responded very good for a given item on Press Ganey survey items and always or definitely yes or 9 or 10 on HCAHPS survey items. CMS utilizes percent top‐box scores to calculate payments under the Value Based Purchasing (VBP) program and to report the results publicly. Numerous studies have also reported percent top‐box scores for HCAHPS survey results.[31, 32, 33, 34]

Odds ratios of premove versus postmove percentage of top‐box scores, adjusted for age, sex, LOS, complexity of illness, and insurance type were determined using logistic regression for the units that moved. Similar scores were calculated for unmoved units to detect secular trends. To determine whether the differences between the moved and unmoved units were significant, we introduced the interaction term (moved vs unmoved unit status) (pre‐ vs postmove time period) into the logistic regression models and examined the adjusted P value for this term. All statistical analysis was performed using SAS Institute Inc.'s (Cary, NC) JMP Pro 10.0.0.

RESULTS

The study included 1648 respondents in the moved units in the baseline period (ie, units designated to move to a new clinical building) and 1373 respondents in the postmove period. There were 1593 respondents in the control group during the baseline period and 1049 respondents in the postmove period. For the units that moved, survey response rates were 28.5% prior to the move and 28.3% after the move. For the units that did not move, survey response rates were 20.9% prior to the move and 22.7% after the move. A majority of survey respondents on the nursing units that moved were white, male, and had private insurance (Table 1). There were no significant differences between respondents across these characteristics between the pre‐ and postmove periods. Mean age and LOS were also similar. For these units, there were 70.5% private rooms prior to the move and 100% after the move. For the unmoved units, 58.9% of the rooms were private in the baseline period and 72.7% were private in the study period. Similar to the units that moved, characteristics of the respondents on the unmoved units also did not differ significantly in the postmove period.

The move was associated with significant improvements in facility‐related satisfaction (Tables 2 and 3). The most prominent increases in satisfaction were with pleasantness of dcor (33.6% vs 66.2%), noise level (39.9% vs 59.3%), and visitor accommodation and comfort (50.0% vs 70.3 %). There was improvement in satisfaction related to cleanliness of the room (49.0% vs 68.6 %), but no significant increase in satisfaction with courtesy of the person cleaning the room (59.8% vs 67.7%) when compared with units that did move.

With regard to nonfacility‐related satisfaction, there were statistically higher scores in several nursing, physician, and discharge‐related satisfaction domains after the move. However, these changes were not associated with the move to the new clinical building as they were not significantly different from improvements on the unmoved units. Among nonfacility‐related items, only staff attitude toward visitors showed significant improvement (68.1% vs 79.4%). There was a significant improvement in hospital rating (75.0% vs 83.3% in the moved units and 75.7% vs 77.6% in the unmoved units). However, the other 3 measures of overall satisfaction did not show significant improvement associated with the move to the new clinical building when compared to the concurrent controls.

DISCUSSION

Contrary to our hypothesis and a belief held by many, we found that patients appeared able to distinguish their experience with hospital environment from their experience with providers and other services. Improvement in hospital facilities with incorporation of patient‐centered features was associated with improvements that were largely limited to increases in satisfaction with quietness, cleanliness, temperature, and dcor of the room along with visitor‐related satisfaction. Notably, there was no significant improvement in satisfaction related to physicians, nurses, housekeeping, and other service staff. There was improvement in satisfaction with staff attitude toward visitors, but this can be attributed to availability of visitor‐friendly facilities. There was a significant improvement in 1 of the 4 measures of overall satisfaction. Our findings also support the construct validity of HCAHPS and Press Ganey patient satisfaction surveys.

Ours is one of the largest studies on patient satisfaction related to patient‐centered design features in the inpatient acute care setting. Swan et al. also studied patients in an acute inpatient setting and compared satisfaction related to appealing versus typical hospital rooms. Patients were matched for case mix, insurance, gender, types of medical services received and LOS, and were served by the same set of physicians and similar food service and housekeeping staff.[26] Unlike our study, they found improved satisfaction related to physicians, housekeeping staff, food service staff, meals, and overall satisfaction. However, the study had some limitations. In particular, the study sample was self‐selected because the patients in this group were required to pay an extra daily fee to utilize the appealing room. Additionally, there were only 177 patients across the 2 groups, and the actual differences in satisfaction scores were small. Our sample was larger and patients in the study group were admitted to units in the new clinical buildings by the same criteria as they were admitted to the historic building prior to the move, and there were no significant differences in baseline characteristics between the comparison groups.

Jansen et al. also found broad improvements in patient satisfaction in a study of over 309 maternity unit patients in a new construction, all private‐room maternity unit with more appealing design elements and comfort features for visitors.[7] Improved satisfaction was noted with the physical environment, nursing care, assistance with feeding, respect for privacy, and discharge planning. However, it is difficult to extrapolate the results of this study to other settings, as maternity unit patients constitute a unique patient demographic with unique care needs. Additionally, when compared with patients in the control group, the patients in the study group were cared for by nurses who had a lower workload and who were not assigned other patients with more complex needs. Because nursing availability may be expected to impact satisfaction with clinical domains, the impact of private and appealing room may very well have been limited to improved satisfaction with the physical environment.

Despite the widespread belief among healthcare leadership that facility renovation or expansion is a vital strategy for improving patient satisfaction, our study shows that this may not be a dominant factor.[27] In fact, the Planetree model showed that improvement in satisfaction related to physical environment and nursing care was associated with implementation of both patient‐centered design features as well as with utilization of nurses that were trained to provide personalized care, educate patients, and involve patients and family.[28] It is more likely that provider‐level interventions will have a greater impact on provider level and overall satisfaction. This idea is supported by a recent JD Powers study suggesting that facilities represent only 19% of overall satisfaction in the inpatient setting.[35]

Although our study focused on patient‐centered design features, several renovation and construction projects have also focused on design features that improve patient safety and provider satisfaction, workflow, efficiency, productivity, stress, and time spent in direct care.[9] Interventions in these areas may lead to improvement in patient outcomes and perhaps lead to improvement in patient satisfaction; however, this relationship has not been well established at present.

In an era of cost containment, healthcare administrators are faced with high‐priced interventions, competing needs, limited resources, low profit margins, and often unclear evidence on cost‐effectiveness and return on investment of healthcare design features. Benefits are related to competitive advantage, higher reputation, patient retention, decreased malpractice costs, and increased Medicare payments through VBP programs that incentivize improved performance on quality metrics and patient satisfaction surveys. Our study supports the idea that a significant improvement in patient satisfaction related to creature comforts can be achieved with investment in patient‐centered design features. However, our findings also suggest that institutions should perform an individualized cost‐benefit analysis related to improvements in this narrow area of patient satisfaction. In our study, incorporation of patient‐centered design features resulted in improvement on 2 VBP HCAHPS measures, and its contribution toward total performance score under the VBP program would be limited.

Strengths of our study include the use of concurrent controls and our ability to capitalize on a natural experiment in which care teams remained constant before and after a move to a new clinical building. However, our study has some limitations. It was conducted at a single tertiary care academic center that predominantly serves an inner city population and referral patients seeking specialized care. Drivers of patient satisfaction may be different in community hospitals, and a different relationship may be observed between patient‐centered design and domains of patient satisfaction in this setting. Further studies in different hospital settings are needed to confirm our findings. Additionally, we were limited by the low response rate of the surveys. However, this is a widespread problem with all patient satisfaction research utilizing voluntary surveys, and our response rates are consistent with those previously reported.[34, 36, 37, 38] Furthermore, low response rates have not impeded the implementation of pay‐for‐performance programs on a national scale using HCHAPS.

In conclusion, our study suggests that hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores. Patients respond positively to creature comforts, pleasing surroundings, and visitor‐friendly facilities but can distinguish these positive experiences from experiences in other patient satisfaction domains. In our study, the move to a higher‐amenity building had only a modest impact on overall patient satisfaction, perhaps because clinical care is the primary driver of this outcome. Contrary to belief held by some hospital leaders, major strides in overall satisfaction across the board and other subdomains of satisfaction likely require intervention in areas other than facility renovation and expansion.

Hospitals are expensive and complex facilities to build and renovate. It is estimated $200 billion is being spent in the United States during this decade on hospital construction and renovation, and further expenditures in this area are expected.[1] Aging hospital infrastructure, competition, and health system expansion have motivated institutions to invest in renovation and new hospital building construction.[2, 3, 4, 5, 6, 7] There is a trend toward patient‐centered design in new hospital construction. Features of this trend include same‐handed design (ie, rooms on a unit have all beds oriented in the same direction and do not share headwalls); use of sound absorbent materials to reduced ambient noise[7, 8, 9]; rooms with improved view and increased natural lighting to reduce anxiety, decrease delirium, and increase sense of wellbeing[10, 11, 12]; incorporation of natural elements like gardens, water features, and art[12, 13, 14, 15, 16, 17, 18]; single‐patient rooms to reduce transmission of infection and enhance privacy and visitor comfort[7, 19, 20]; presence of comfortable waiting rooms and visitor accommodations to enhance comfort and family participation[21, 22, 23]; and hotel‐like amenities such as on‐demand entertainment and room service menus.[24, 25]

There is a belief among some hospital leaders that patients are generally unable to distinguish their positive experience with a pleasing healthcare environment from their positive experience with care, and thus improving facilities will lead to improved satisfaction across the board.[26, 27] In a controlled study of hospitalized patients, appealing rooms were associated with increased satisfaction with services including housekeeping and food service staff, meals, as well as physicians and overall satisfaction.[26] A 2012 survey of hospital leadership found that expanding and renovating facilities was considered a top priority in improving patient satisfaction, with 82% of the respondents stating that this was important.[27]

Despite these attitudes, the impact of patient‐centered design on patient satisfaction is not well understood. Studies have shown that renovations and hospital construction that incorporates noise reduction strategies, positive distraction, patient and caregiver control, attractive waiting rooms, improved patient room appearance, private rooms, and large windows result in improved satisfaction with nursing, noise level, unit environment and cleanliness, perceived wait time, discharge preparedness, and overall care. [7, 19, 20, 23, 28] However, these studies were limited by small sample size, inclusion of a narrow group of patients (eg, ambulatory, obstetric, geriatric rehabilitation, intensive care unit), and concurrent use of interventions other than design improvement (eg, nurse and patient education). Many of these studies did not use the ubiquitous Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient satisfaction surveys.

We sought to determine the changes in patient satisfaction that occurred during a natural experiment, in which clinical units (comprising stable nursing, physician, and unit teams) were relocated from an historic clinical building to a new clinical building that featured patient‐centered design, using HCAHPS and Press Ganey surveys and a large study population. We hypothesized that new building features would positively impact both facility related (eg, noise level), nonfacility related (eg, physician and housekeeping service related), and overall satisfaction.

METHODS

This was a retrospective analysis of prospectively collected Press Ganey and HCAPHS patient satisfaction survey data for a single academic tertiary care hospital.[29] The research project was reviewed and approved by the institutional review board.

Statistical Analysis

Percent top‐box scores were calculated for each survey item as the percent of patients who responded very good for a given item on Press Ganey survey items and always or definitely yes or 9 or 10 on HCAHPS survey items. CMS utilizes percent top‐box scores to calculate payments under the Value Based Purchasing (VBP) program and to report the results publicly. Numerous studies have also reported percent top‐box scores for HCAHPS survey results.[31, 32, 33, 34]

Odds ratios of premove versus postmove percentage of top‐box scores, adjusted for age, sex, LOS, complexity of illness, and insurance type were determined using logistic regression for the units that moved. Similar scores were calculated for unmoved units to detect secular trends. To determine whether the differences between the moved and unmoved units were significant, we introduced the interaction term (moved vs unmoved unit status) (pre‐ vs postmove time period) into the logistic regression models and examined the adjusted P value for this term. All statistical analysis was performed using SAS Institute Inc.'s (Cary, NC) JMP Pro 10.0.0.

RESULTS

The study included 1648 respondents in the moved units in the baseline period (ie, units designated to move to a new clinical building) and 1373 respondents in the postmove period. There were 1593 respondents in the control group during the baseline period and 1049 respondents in the postmove period. For the units that moved, survey response rates were 28.5% prior to the move and 28.3% after the move. For the units that did not move, survey response rates were 20.9% prior to the move and 22.7% after the move. A majority of survey respondents on the nursing units that moved were white, male, and had private insurance (Table 1). There were no significant differences between respondents across these characteristics between the pre‐ and postmove periods. Mean age and LOS were also similar. For these units, there were 70.5% private rooms prior to the move and 100% after the move. For the unmoved units, 58.9% of the rooms were private in the baseline period and 72.7% were private in the study period. Similar to the units that moved, characteristics of the respondents on the unmoved units also did not differ significantly in the postmove period.

The move was associated with significant improvements in facility‐related satisfaction (Tables 2 and 3). The most prominent increases in satisfaction were with pleasantness of dcor (33.6% vs 66.2%), noise level (39.9% vs 59.3%), and visitor accommodation and comfort (50.0% vs 70.3 %). There was improvement in satisfaction related to cleanliness of the room (49.0% vs 68.6 %), but no significant increase in satisfaction with courtesy of the person cleaning the room (59.8% vs 67.7%) when compared with units that did move.

With regard to nonfacility‐related satisfaction, there were statistically higher scores in several nursing, physician, and discharge‐related satisfaction domains after the move. However, these changes were not associated with the move to the new clinical building as they were not significantly different from improvements on the unmoved units. Among nonfacility‐related items, only staff attitude toward visitors showed significant improvement (68.1% vs 79.4%). There was a significant improvement in hospital rating (75.0% vs 83.3% in the moved units and 75.7% vs 77.6% in the unmoved units). However, the other 3 measures of overall satisfaction did not show significant improvement associated with the move to the new clinical building when compared to the concurrent controls.

DISCUSSION

Contrary to our hypothesis and a belief held by many, we found that patients appeared able to distinguish their experience with hospital environment from their experience with providers and other services. Improvement in hospital facilities with incorporation of patient‐centered features was associated with improvements that were largely limited to increases in satisfaction with quietness, cleanliness, temperature, and dcor of the room along with visitor‐related satisfaction. Notably, there was no significant improvement in satisfaction related to physicians, nurses, housekeeping, and other service staff. There was improvement in satisfaction with staff attitude toward visitors, but this can be attributed to availability of visitor‐friendly facilities. There was a significant improvement in 1 of the 4 measures of overall satisfaction. Our findings also support the construct validity of HCAHPS and Press Ganey patient satisfaction surveys.

Ours is one of the largest studies on patient satisfaction related to patient‐centered design features in the inpatient acute care setting. Swan et al. also studied patients in an acute inpatient setting and compared satisfaction related to appealing versus typical hospital rooms. Patients were matched for case mix, insurance, gender, types of medical services received and LOS, and were served by the same set of physicians and similar food service and housekeeping staff.[26] Unlike our study, they found improved satisfaction related to physicians, housekeeping staff, food service staff, meals, and overall satisfaction. However, the study had some limitations. In particular, the study sample was self‐selected because the patients in this group were required to pay an extra daily fee to utilize the appealing room. Additionally, there were only 177 patients across the 2 groups, and the actual differences in satisfaction scores were small. Our sample was larger and patients in the study group were admitted to units in the new clinical buildings by the same criteria as they were admitted to the historic building prior to the move, and there were no significant differences in baseline characteristics between the comparison groups.

Jansen et al. also found broad improvements in patient satisfaction in a study of over 309 maternity unit patients in a new construction, all private‐room maternity unit with more appealing design elements and comfort features for visitors.[7] Improved satisfaction was noted with the physical environment, nursing care, assistance with feeding, respect for privacy, and discharge planning. However, it is difficult to extrapolate the results of this study to other settings, as maternity unit patients constitute a unique patient demographic with unique care needs. Additionally, when compared with patients in the control group, the patients in the study group were cared for by nurses who had a lower workload and who were not assigned other patients with more complex needs. Because nursing availability may be expected to impact satisfaction with clinical domains, the impact of private and appealing room may very well have been limited to improved satisfaction with the physical environment.

Despite the widespread belief among healthcare leadership that facility renovation or expansion is a vital strategy for improving patient satisfaction, our study shows that this may not be a dominant factor.[27] In fact, the Planetree model showed that improvement in satisfaction related to physical environment and nursing care was associated with implementation of both patient‐centered design features as well as with utilization of nurses that were trained to provide personalized care, educate patients, and involve patients and family.[28] It is more likely that provider‐level interventions will have a greater impact on provider level and overall satisfaction. This idea is supported by a recent JD Powers study suggesting that facilities represent only 19% of overall satisfaction in the inpatient setting.[35]

Although our study focused on patient‐centered design features, several renovation and construction projects have also focused on design features that improve patient safety and provider satisfaction, workflow, efficiency, productivity, stress, and time spent in direct care.[9] Interventions in these areas may lead to improvement in patient outcomes and perhaps lead to improvement in patient satisfaction; however, this relationship has not been well established at present.

In an era of cost containment, healthcare administrators are faced with high‐priced interventions, competing needs, limited resources, low profit margins, and often unclear evidence on cost‐effectiveness and return on investment of healthcare design features. Benefits are related to competitive advantage, higher reputation, patient retention, decreased malpractice costs, and increased Medicare payments through VBP programs that incentivize improved performance on quality metrics and patient satisfaction surveys. Our study supports the idea that a significant improvement in patient satisfaction related to creature comforts can be achieved with investment in patient‐centered design features. However, our findings also suggest that institutions should perform an individualized cost‐benefit analysis related to improvements in this narrow area of patient satisfaction. In our study, incorporation of patient‐centered design features resulted in improvement on 2 VBP HCAHPS measures, and its contribution toward total performance score under the VBP program would be limited.

Strengths of our study include the use of concurrent controls and our ability to capitalize on a natural experiment in which care teams remained constant before and after a move to a new clinical building. However, our study has some limitations. It was conducted at a single tertiary care academic center that predominantly serves an inner city population and referral patients seeking specialized care. Drivers of patient satisfaction may be different in community hospitals, and a different relationship may be observed between patient‐centered design and domains of patient satisfaction in this setting. Further studies in different hospital settings are needed to confirm our findings. Additionally, we were limited by the low response rate of the surveys. However, this is a widespread problem with all patient satisfaction research utilizing voluntary surveys, and our response rates are consistent with those previously reported.[34, 36, 37, 38] Furthermore, low response rates have not impeded the implementation of pay‐for‐performance programs on a national scale using HCHAPS.

In conclusion, our study suggests that hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores. Patients respond positively to creature comforts, pleasing surroundings, and visitor‐friendly facilities but can distinguish these positive experiences from experiences in other patient satisfaction domains. In our study, the move to a higher‐amenity building had only a modest impact on overall patient satisfaction, perhaps because clinical care is the primary driver of this outcome. Contrary to belief held by some hospital leaders, major strides in overall satisfaction across the board and other subdomains of satisfaction likely require intervention in areas other than facility renovation and expansion.

Hospitals are expensive and complex facilities to build and renovate. It is estimated $200 billion is being spent in the United States during this decade on hospital construction and renovation, and further expenditures in this area are expected.[1] Aging hospital infrastructure, competition, and health system expansion have motivated institutions to invest in renovation and new hospital building construction.[2, 3, 4, 5, 6, 7] There is a trend toward patient‐centered design in new hospital construction. Features of this trend include same‐handed design (ie, rooms on a unit have all beds oriented in the same direction and do not share headwalls); use of sound absorbent materials to reduced ambient noise[7, 8, 9]; rooms with improved view and increased natural lighting to reduce anxiety, decrease delirium, and increase sense of wellbeing[10, 11, 12]; incorporation of natural elements like gardens, water features, and art[12, 13, 14, 15, 16, 17, 18]; single‐patient rooms to reduce transmission of infection and enhance privacy and visitor comfort[7, 19, 20]; presence of comfortable waiting rooms and visitor accommodations to enhance comfort and family participation[21, 22, 23]; and hotel‐like amenities such as on‐demand entertainment and room service menus.[24, 25]

There is a belief among some hospital leaders that patients are generally unable to distinguish their positive experience with a pleasing healthcare environment from their positive experience with care, and thus improving facilities will lead to improved satisfaction across the board.[26, 27] In a controlled study of hospitalized patients, appealing rooms were associated with increased satisfaction with services including housekeeping and food service staff, meals, as well as physicians and overall satisfaction.[26] A 2012 survey of hospital leadership found that expanding and renovating facilities was considered a top priority in improving patient satisfaction, with 82% of the respondents stating that this was important.[27]

Despite these attitudes, the impact of patient‐centered design on patient satisfaction is not well understood. Studies have shown that renovations and hospital construction that incorporates noise reduction strategies, positive distraction, patient and caregiver control, attractive waiting rooms, improved patient room appearance, private rooms, and large windows result in improved satisfaction with nursing, noise level, unit environment and cleanliness, perceived wait time, discharge preparedness, and overall care. [7, 19, 20, 23, 28] However, these studies were limited by small sample size, inclusion of a narrow group of patients (eg, ambulatory, obstetric, geriatric rehabilitation, intensive care unit), and concurrent use of interventions other than design improvement (eg, nurse and patient education). Many of these studies did not use the ubiquitous Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient satisfaction surveys.

We sought to determine the changes in patient satisfaction that occurred during a natural experiment, in which clinical units (comprising stable nursing, physician, and unit teams) were relocated from an historic clinical building to a new clinical building that featured patient‐centered design, using HCAHPS and Press Ganey surveys and a large study population. We hypothesized that new building features would positively impact both facility related (eg, noise level), nonfacility related (eg, physician and housekeeping service related), and overall satisfaction.

METHODS

This was a retrospective analysis of prospectively collected Press Ganey and HCAPHS patient satisfaction survey data for a single academic tertiary care hospital.[29] The research project was reviewed and approved by the institutional review board.

Statistical Analysis

Percent top‐box scores were calculated for each survey item as the percent of patients who responded very good for a given item on Press Ganey survey items and always or definitely yes or 9 or 10 on HCAHPS survey items. CMS utilizes percent top‐box scores to calculate payments under the Value Based Purchasing (VBP) program and to report the results publicly. Numerous studies have also reported percent top‐box scores for HCAHPS survey results.[31, 32, 33, 34]

Odds ratios of premove versus postmove percentage of top‐box scores, adjusted for age, sex, LOS, complexity of illness, and insurance type were determined using logistic regression for the units that moved. Similar scores were calculated for unmoved units to detect secular trends. To determine whether the differences between the moved and unmoved units were significant, we introduced the interaction term (moved vs unmoved unit status) (pre‐ vs postmove time period) into the logistic regression models and examined the adjusted P value for this term. All statistical analysis was performed using SAS Institute Inc.'s (Cary, NC) JMP Pro 10.0.0.

RESULTS

The study included 1648 respondents in the moved units in the baseline period (ie, units designated to move to a new clinical building) and 1373 respondents in the postmove period. There were 1593 respondents in the control group during the baseline period and 1049 respondents in the postmove period. For the units that moved, survey response rates were 28.5% prior to the move and 28.3% after the move. For the units that did not move, survey response rates were 20.9% prior to the move and 22.7% after the move. A majority of survey respondents on the nursing units that moved were white, male, and had private insurance (Table 1). There were no significant differences between respondents across these characteristics between the pre‐ and postmove periods. Mean age and LOS were also similar. For these units, there were 70.5% private rooms prior to the move and 100% after the move. For the unmoved units, 58.9% of the rooms were private in the baseline period and 72.7% were private in the study period. Similar to the units that moved, characteristics of the respondents on the unmoved units also did not differ significantly in the postmove period.

The move was associated with significant improvements in facility‐related satisfaction (Tables 2 and 3). The most prominent increases in satisfaction were with pleasantness of dcor (33.6% vs 66.2%), noise level (39.9% vs 59.3%), and visitor accommodation and comfort (50.0% vs 70.3 %). There was improvement in satisfaction related to cleanliness of the room (49.0% vs 68.6 %), but no significant increase in satisfaction with courtesy of the person cleaning the room (59.8% vs 67.7%) when compared with units that did move.

With regard to nonfacility‐related satisfaction, there were statistically higher scores in several nursing, physician, and discharge‐related satisfaction domains after the move. However, these changes were not associated with the move to the new clinical building as they were not significantly different from improvements on the unmoved units. Among nonfacility‐related items, only staff attitude toward visitors showed significant improvement (68.1% vs 79.4%). There was a significant improvement in hospital rating (75.0% vs 83.3% in the moved units and 75.7% vs 77.6% in the unmoved units). However, the other 3 measures of overall satisfaction did not show significant improvement associated with the move to the new clinical building when compared to the concurrent controls.

DISCUSSION

Contrary to our hypothesis and a belief held by many, we found that patients appeared able to distinguish their experience with hospital environment from their experience with providers and other services. Improvement in hospital facilities with incorporation of patient‐centered features was associated with improvements that were largely limited to increases in satisfaction with quietness, cleanliness, temperature, and dcor of the room along with visitor‐related satisfaction. Notably, there was no significant improvement in satisfaction related to physicians, nurses, housekeeping, and other service staff. There was improvement in satisfaction with staff attitude toward visitors, but this can be attributed to availability of visitor‐friendly facilities. There was a significant improvement in 1 of the 4 measures of overall satisfaction. Our findings also support the construct validity of HCAHPS and Press Ganey patient satisfaction surveys.

Ours is one of the largest studies on patient satisfaction related to patient‐centered design features in the inpatient acute care setting. Swan et al. also studied patients in an acute inpatient setting and compared satisfaction related to appealing versus typical hospital rooms. Patients were matched for case mix, insurance, gender, types of medical services received and LOS, and were served by the same set of physicians and similar food service and housekeeping staff.[26] Unlike our study, they found improved satisfaction related to physicians, housekeeping staff, food service staff, meals, and overall satisfaction. However, the study had some limitations. In particular, the study sample was self‐selected because the patients in this group were required to pay an extra daily fee to utilize the appealing room. Additionally, there were only 177 patients across the 2 groups, and the actual differences in satisfaction scores were small. Our sample was larger and patients in the study group were admitted to units in the new clinical buildings by the same criteria as they were admitted to the historic building prior to the move, and there were no significant differences in baseline characteristics between the comparison groups.

Jansen et al. also found broad improvements in patient satisfaction in a study of over 309 maternity unit patients in a new construction, all private‐room maternity unit with more appealing design elements and comfort features for visitors.[7] Improved satisfaction was noted with the physical environment, nursing care, assistance with feeding, respect for privacy, and discharge planning. However, it is difficult to extrapolate the results of this study to other settings, as maternity unit patients constitute a unique patient demographic with unique care needs. Additionally, when compared with patients in the control group, the patients in the study group were cared for by nurses who had a lower workload and who were not assigned other patients with more complex needs. Because nursing availability may be expected to impact satisfaction with clinical domains, the impact of private and appealing room may very well have been limited to improved satisfaction with the physical environment.

Despite the widespread belief among healthcare leadership that facility renovation or expansion is a vital strategy for improving patient satisfaction, our study shows that this may not be a dominant factor.[27] In fact, the Planetree model showed that improvement in satisfaction related to physical environment and nursing care was associated with implementation of both patient‐centered design features as well as with utilization of nurses that were trained to provide personalized care, educate patients, and involve patients and family.[28] It is more likely that provider‐level interventions will have a greater impact on provider level and overall satisfaction. This idea is supported by a recent JD Powers study suggesting that facilities represent only 19% of overall satisfaction in the inpatient setting.[35]

Although our study focused on patient‐centered design features, several renovation and construction projects have also focused on design features that improve patient safety and provider satisfaction, workflow, efficiency, productivity, stress, and time spent in direct care.[9] Interventions in these areas may lead to improvement in patient outcomes and perhaps lead to improvement in patient satisfaction; however, this relationship has not been well established at present.

In an era of cost containment, healthcare administrators are faced with high‐priced interventions, competing needs, limited resources, low profit margins, and often unclear evidence on cost‐effectiveness and return on investment of healthcare design features. Benefits are related to competitive advantage, higher reputation, patient retention, decreased malpractice costs, and increased Medicare payments through VBP programs that incentivize improved performance on quality metrics and patient satisfaction surveys. Our study supports the idea that a significant improvement in patient satisfaction related to creature comforts can be achieved with investment in patient‐centered design features. However, our findings also suggest that institutions should perform an individualized cost‐benefit analysis related to improvements in this narrow area of patient satisfaction. In our study, incorporation of patient‐centered design features resulted in improvement on 2 VBP HCAHPS measures, and its contribution toward total performance score under the VBP program would be limited.

Strengths of our study include the use of concurrent controls and our ability to capitalize on a natural experiment in which care teams remained constant before and after a move to a new clinical building. However, our study has some limitations. It was conducted at a single tertiary care academic center that predominantly serves an inner city population and referral patients seeking specialized care. Drivers of patient satisfaction may be different in community hospitals, and a different relationship may be observed between patient‐centered design and domains of patient satisfaction in this setting. Further studies in different hospital settings are needed to confirm our findings. Additionally, we were limited by the low response rate of the surveys. However, this is a widespread problem with all patient satisfaction research utilizing voluntary surveys, and our response rates are consistent with those previously reported.[34, 36, 37, 38] Furthermore, low response rates have not impeded the implementation of pay‐for‐performance programs on a national scale using HCHAPS.

In conclusion, our study suggests that hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores. Patients respond positively to creature comforts, pleasing surroundings, and visitor‐friendly facilities but can distinguish these positive experiences from experiences in other patient satisfaction domains. In our study, the move to a higher‐amenity building had only a modest impact on overall patient satisfaction, perhaps because clinical care is the primary driver of this outcome. Contrary to belief held by some hospital leaders, major strides in overall satisfaction across the board and other subdomains of satisfaction likely require intervention in areas other than facility renovation and expansion.

Patient satisfaction surveys are widely used to empower patients to voice their concerns and point out areas of deficiency or excellence in the patient‐physician partnership and in the delivery of healthcare services.[1] In 2002, the Centers for Medicare and Medicaid Service (CMS) led an initiative to develop the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questionnaire.[2] This survey is sent to a randomly selected subset of patients after hospital discharge. The HCAHPS instrument assesses patient ratings of physician communication, nursing communication, pain control, responsiveness, room cleanliness and quietness, discharge process, and overall satisfaction. Over 4500 acute‐care facilities routinely use this survey.[3] HCAHPS scores are publicly reported, and patients can utilize these scores to compare hospitals and make informed choices about where to get care. At an institutional level, scores are used as a tool to identify and improve deficiencies in care delivery. Additionally, HCAHPS survey data results have been analyzed in numerous research studies.[4, 5, 6]

Specialty hospitals are a subset of acute‐care hospitals that provide a narrower set of services than general medical hospitals (GMHs), predominantly in a few specialty areas such as cardiac disease and surgical fields. Many specialty hospitals advertise high rates of patient satisfaction.[7, 8, 9, 10, 11] However, specialty hospitals differ from GMHs in significant ways. Patients at specialty hospitals may be less severely ill[10, 12] and may have more generous insurance coverage.[13] Many specialty hospitals do not have an emergency department (ED), and their outcomes may reflect care of relatively stable patients.[14] A significant number of the specialty hospitals are physician‐owned, which may provide an opportunity for physicians to deliver more patient‐focused healthcare.[14] It is also thought that specialty hospitals can provide high‐quality care by designing their facilities and service structure entirely to meet the needs of a narrow set of medical conditions.

HCAHPS survey results provide an opportunity to compare satisfaction scores among various types of hospitals. We analyzed national HCAHPS data to compare satisfaction scores of specialty hospitals and GMHs and identify factors that may be responsible for this difference.

METHODS

This was a cross‐sectional analysis of national HCAHPS survey data. The methods for administration and reporting of the HCAHPS survey have been described.[15] HCAHPS patient satisfaction data and hospital characteristics, such as location, presence of an ED, and for‐profit status, were obtained from Hospital Compare database. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16]

For this study, we defined specialty hospitals as acute‐care hospitals that predominantly provide care in a medical or surgical specialty and do not provide care to general medical patients. Based on this definition, specialty hospitals include cardiac hospitals, orthopedic and spine hospitals, oncology hospitals, and hospitals providing multispecialty surgical and procedure‐based services. Children's hospitals, long‐term acute‐care hospitals, and psychiatry hospitals were excluded.

Specialty hospitals were identified using hospital name searches in the HCAHPS database, the American Hospital Association 2013 Annual Survey, the Physician Hospital Association hospitals directory, and through contact with experts. The specialty hospital status of hospitals was further confirmed by checking hospital websites or by directly contacting the hospital.

We analyzed 3‐year HCAHPS patient satisfaction data that included the reporting period from July 2007 to June 2010. HCAHPS data are reported for 12‐month periods at a time. Hospital information, such as address, presence of an ED, and for‐profit status were obtained from the CMS Hospital Compare 2010 dataset. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16] For the purpose of this study, scores on the HCAHPS survey item definitely recommend the hospital was considered to represent overall satisfaction for the hospital. This is consistent with use of this measure in other sectors in the service industry.[17, 18] Other survey items were considered subdomains of satisfaction. For each hospital, the simple mean of satisfaction scores for overall satisfaction and each of the subdomains for the three 12‐month periods was calculated. Data were summarized using frequencies and meanstandard deviation. The primary dependent variable was overall satisfaction. The main independent variables were specialty hospital status (yes or no), teaching hospital status (yes or no), for‐profit status (yes or no), and the presence of an ED (yes or no). Multiple linear regression analysis was used to adjust for the above‐noted independent variables. A P value<0.05 was considered significant. All analyses were performed on Stata 10.1 IC (StataCorp, College Station, TX).

RESULTS

We identified 188 specialty hospitals and 4638 GMHs within the HCAHPS dataset. Fewer specialty hospitals had emergency care services when compared with GMHs (53.2% for specialty hospitals vs 93.6% for GMHs, P<0.0001), and 47.9% of all specialty hospitals were in states that do not require a Certificate of Need, whereas only 25% of all GMHs were present in these states. For example, Texas, which has 7.2% of all GMHs across the nation, has 24.7% of all specialty hospitals. As compared to GMHs, a majority of specialty hospitals were for profit (14.5% vs 66.9%).

In unadjusted analyses, specialty hospitals had significantly higher patient satisfaction scores compared with GMHs. Overall satisfaction, as measured by the proportion of patients that will definitely recommend that hospital, was 18.8% higher for specialty hospitals than GMHs (86.6% vs 67.8%, P<0.0001). This was also true for subdomains of satisfaction including physician communication, nursing communication, and cleanliness (Table 1).

We next examined the effect of survey response rate. The survey response rate for specialty hospitals was on average 17.4 percentage points higher than that of GMHs (49.6% vs 32.2%, P<0.0001). When adjusted for survey response rate, the difference in overall satisfaction for specialty hospitals was reduced to 8.6% (6.7%10.5%, P<0.0001). Similarly, the differences in score for subdomains of satisfaction were more modest when adjusted for higher survey response rate. In the multiple regression models, specialty hospital status, survey response rate, for‐profit status, and the presence of an ED were independently associated with higher overall satisfaction, whereas teaching hospital status was not associated with overall satisfaction. Addition of for‐profit status and presence of an ED in the regression model did not change our results. Further, the satisfaction subdomain scores for specialty hospitals remained significantly higher than for GMHs in the regression models (Table 1).

DISCUSSION

In this national study, we found that specialty hospitals had significantly higher overall satisfaction scores on the HCAHPS satisfaction survey. Similarly, significantly higher satisfaction was noted across all the satisfaction subdomains. We found that a large proportion of the difference between specialty hospitals and GMHs in overall satisfaction and subdomains of satisfaction could be explained by a higher survey response rate in specialty hospitals. After adjusting for survey response rate, the differences were comparatively modest, although remained statistically significant. Adjustment for additional confounding variables did not change our results.

Studies have shown that specialty hospitals, when compared to GMHs, may treat more patients in their area of specialization, care for fewer sick and Medicaid patients, have greater physician ownership, and are less likely to have ED services.[11, 12, 13, 14] Two small studies comparing specialty hospitals to GMHs suggest that higher satisfaction with specialty hospitals was attributable to the presence of private rooms, quiet environment, accommodation for family members, and accessible, attentive, and well‐trained nursing staff.[10, 11] Although our analysis did not account for various other hospital and patient characteristics, we expect that these factors likely play a significant role in the observed differences in patient satisfaction.

Survey response rate can be an important determinant of the validity of survey results, and a response rate >70% is often considered desirable.[19, 20] However, the mean survey response rate for the HCAHPS survey was only 32.8% for all hospitals during the survey period. In the outpatient setting, a higher survey response rate has been shown to be associated with higher satisfaction rates.[21] In the hospital setting, a randomized study of a HCAHPS survey for 45 hospitals found that patient mix explained the nonresponse bias. However, this study did not examine the roles of severity of illness or insurance status, which may account for the differences in satisfaction seen between specialty hospitals and GMHs.[22] In contrast, we found that in the hospital setting, higher survey response rate was associated with higher patient satisfaction scores.

Our study has some limitations. First, it was not possible to determine from the dataset whether higher response rate is a result of differences in the patient population characteristics between specialty hospitals and GMHs or it represents the association between higher satisfaction and higher response rate noted by other investigators. Although we used various resources to identify all specialty hospitals, we may have missed some or misclassified others due to lack of a standardized definition.[10, 12, 13] However, the total number of specialty hospitals and their distribution across various states in the current study are consistent with previous studies, supporting our belief that few, if any, hospitals were misclassified.[13]

In summary, we found significant difference in satisfaction rates reported on HCAHPS in a national study of patients attending specialty hospitals versus GMHs. However, the observed differences in satisfaction scores were sensitive to differences in survey response rates among hospitals. Teaching hospital status, for‐profit status, and the presence of an ED did not appear to further explain the differences. Additional studies incorporating other hospital and patient characteristics are needed to fully understand factors associated with differences in the observed patient satisfaction between specialty hospitals and GMHs. Additionally, strategies to increase survey HCAHPS response rates should be a priority.

Patient satisfaction surveys are widely used to empower patients to voice their concerns and point out areas of deficiency or excellence in the patient‐physician partnership and in the delivery of healthcare services.[1] In 2002, the Centers for Medicare and Medicaid Service (CMS) led an initiative to develop the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questionnaire.[2] This survey is sent to a randomly selected subset of patients after hospital discharge. The HCAHPS instrument assesses patient ratings of physician communication, nursing communication, pain control, responsiveness, room cleanliness and quietness, discharge process, and overall satisfaction. Over 4500 acute‐care facilities routinely use this survey.[3] HCAHPS scores are publicly reported, and patients can utilize these scores to compare hospitals and make informed choices about where to get care. At an institutional level, scores are used as a tool to identify and improve deficiencies in care delivery. Additionally, HCAHPS survey data results have been analyzed in numerous research studies.[4, 5, 6]

Specialty hospitals are a subset of acute‐care hospitals that provide a narrower set of services than general medical hospitals (GMHs), predominantly in a few specialty areas such as cardiac disease and surgical fields. Many specialty hospitals advertise high rates of patient satisfaction.[7, 8, 9, 10, 11] However, specialty hospitals differ from GMHs in significant ways. Patients at specialty hospitals may be less severely ill[10, 12] and may have more generous insurance coverage.[13] Many specialty hospitals do not have an emergency department (ED), and their outcomes may reflect care of relatively stable patients.[14] A significant number of the specialty hospitals are physician‐owned, which may provide an opportunity for physicians to deliver more patient‐focused healthcare.[14] It is also thought that specialty hospitals can provide high‐quality care by designing their facilities and service structure entirely to meet the needs of a narrow set of medical conditions.

HCAHPS survey results provide an opportunity to compare satisfaction scores among various types of hospitals. We analyzed national HCAHPS data to compare satisfaction scores of specialty hospitals and GMHs and identify factors that may be responsible for this difference.

METHODS

This was a cross‐sectional analysis of national HCAHPS survey data. The methods for administration and reporting of the HCAHPS survey have been described.[15] HCAHPS patient satisfaction data and hospital characteristics, such as location, presence of an ED, and for‐profit status, were obtained from Hospital Compare database. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16]

For this study, we defined specialty hospitals as acute‐care hospitals that predominantly provide care in a medical or surgical specialty and do not provide care to general medical patients. Based on this definition, specialty hospitals include cardiac hospitals, orthopedic and spine hospitals, oncology hospitals, and hospitals providing multispecialty surgical and procedure‐based services. Children's hospitals, long‐term acute‐care hospitals, and psychiatry hospitals were excluded.

Specialty hospitals were identified using hospital name searches in the HCAHPS database, the American Hospital Association 2013 Annual Survey, the Physician Hospital Association hospitals directory, and through contact with experts. The specialty hospital status of hospitals was further confirmed by checking hospital websites or by directly contacting the hospital.

We analyzed 3‐year HCAHPS patient satisfaction data that included the reporting period from July 2007 to June 2010. HCAHPS data are reported for 12‐month periods at a time. Hospital information, such as address, presence of an ED, and for‐profit status were obtained from the CMS Hospital Compare 2010 dataset. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16] For the purpose of this study, scores on the HCAHPS survey item definitely recommend the hospital was considered to represent overall satisfaction for the hospital. This is consistent with use of this measure in other sectors in the service industry.[17, 18] Other survey items were considered subdomains of satisfaction. For each hospital, the simple mean of satisfaction scores for overall satisfaction and each of the subdomains for the three 12‐month periods was calculated. Data were summarized using frequencies and meanstandard deviation. The primary dependent variable was overall satisfaction. The main independent variables were specialty hospital status (yes or no), teaching hospital status (yes or no), for‐profit status (yes or no), and the presence of an ED (yes or no). Multiple linear regression analysis was used to adjust for the above‐noted independent variables. A P value<0.05 was considered significant. All analyses were performed on Stata 10.1 IC (StataCorp, College Station, TX).

RESULTS

We identified 188 specialty hospitals and 4638 GMHs within the HCAHPS dataset. Fewer specialty hospitals had emergency care services when compared with GMHs (53.2% for specialty hospitals vs 93.6% for GMHs, P<0.0001), and 47.9% of all specialty hospitals were in states that do not require a Certificate of Need, whereas only 25% of all GMHs were present in these states. For example, Texas, which has 7.2% of all GMHs across the nation, has 24.7% of all specialty hospitals. As compared to GMHs, a majority of specialty hospitals were for profit (14.5% vs 66.9%).

In unadjusted analyses, specialty hospitals had significantly higher patient satisfaction scores compared with GMHs. Overall satisfaction, as measured by the proportion of patients that will definitely recommend that hospital, was 18.8% higher for specialty hospitals than GMHs (86.6% vs 67.8%, P<0.0001). This was also true for subdomains of satisfaction including physician communication, nursing communication, and cleanliness (Table 1).

We next examined the effect of survey response rate. The survey response rate for specialty hospitals was on average 17.4 percentage points higher than that of GMHs (49.6% vs 32.2%, P<0.0001). When adjusted for survey response rate, the difference in overall satisfaction for specialty hospitals was reduced to 8.6% (6.7%10.5%, P<0.0001). Similarly, the differences in score for subdomains of satisfaction were more modest when adjusted for higher survey response rate. In the multiple regression models, specialty hospital status, survey response rate, for‐profit status, and the presence of an ED were independently associated with higher overall satisfaction, whereas teaching hospital status was not associated with overall satisfaction. Addition of for‐profit status and presence of an ED in the regression model did not change our results. Further, the satisfaction subdomain scores for specialty hospitals remained significantly higher than for GMHs in the regression models (Table 1).

DISCUSSION

In this national study, we found that specialty hospitals had significantly higher overall satisfaction scores on the HCAHPS satisfaction survey. Similarly, significantly higher satisfaction was noted across all the satisfaction subdomains. We found that a large proportion of the difference between specialty hospitals and GMHs in overall satisfaction and subdomains of satisfaction could be explained by a higher survey response rate in specialty hospitals. After adjusting for survey response rate, the differences were comparatively modest, although remained statistically significant. Adjustment for additional confounding variables did not change our results.

Studies have shown that specialty hospitals, when compared to GMHs, may treat more patients in their area of specialization, care for fewer sick and Medicaid patients, have greater physician ownership, and are less likely to have ED services.[11, 12, 13, 14] Two small studies comparing specialty hospitals to GMHs suggest that higher satisfaction with specialty hospitals was attributable to the presence of private rooms, quiet environment, accommodation for family members, and accessible, attentive, and well‐trained nursing staff.[10, 11] Although our analysis did not account for various other hospital and patient characteristics, we expect that these factors likely play a significant role in the observed differences in patient satisfaction.

Survey response rate can be an important determinant of the validity of survey results, and a response rate >70% is often considered desirable.[19, 20] However, the mean survey response rate for the HCAHPS survey was only 32.8% for all hospitals during the survey period. In the outpatient setting, a higher survey response rate has been shown to be associated with higher satisfaction rates.[21] In the hospital setting, a randomized study of a HCAHPS survey for 45 hospitals found that patient mix explained the nonresponse bias. However, this study did not examine the roles of severity of illness or insurance status, which may account for the differences in satisfaction seen between specialty hospitals and GMHs.[22] In contrast, we found that in the hospital setting, higher survey response rate was associated with higher patient satisfaction scores.

Our study has some limitations. First, it was not possible to determine from the dataset whether higher response rate is a result of differences in the patient population characteristics between specialty hospitals and GMHs or it represents the association between higher satisfaction and higher response rate noted by other investigators. Although we used various resources to identify all specialty hospitals, we may have missed some or misclassified others due to lack of a standardized definition.[10, 12, 13] However, the total number of specialty hospitals and their distribution across various states in the current study are consistent with previous studies, supporting our belief that few, if any, hospitals were misclassified.[13]

In summary, we found significant difference in satisfaction rates reported on HCAHPS in a national study of patients attending specialty hospitals versus GMHs. However, the observed differences in satisfaction scores were sensitive to differences in survey response rates among hospitals. Teaching hospital status, for‐profit status, and the presence of an ED did not appear to further explain the differences. Additional studies incorporating other hospital and patient characteristics are needed to fully understand factors associated with differences in the observed patient satisfaction between specialty hospitals and GMHs. Additionally, strategies to increase survey HCAHPS response rates should be a priority.

Patient satisfaction surveys are widely used to empower patients to voice their concerns and point out areas of deficiency or excellence in the patient‐physician partnership and in the delivery of healthcare services.[1] In 2002, the Centers for Medicare and Medicaid Service (CMS) led an initiative to develop the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questionnaire.[2] This survey is sent to a randomly selected subset of patients after hospital discharge. The HCAHPS instrument assesses patient ratings of physician communication, nursing communication, pain control, responsiveness, room cleanliness and quietness, discharge process, and overall satisfaction. Over 4500 acute‐care facilities routinely use this survey.[3] HCAHPS scores are publicly reported, and patients can utilize these scores to compare hospitals and make informed choices about where to get care. At an institutional level, scores are used as a tool to identify and improve deficiencies in care delivery. Additionally, HCAHPS survey data results have been analyzed in numerous research studies.[4, 5, 6]

Specialty hospitals are a subset of acute‐care hospitals that provide a narrower set of services than general medical hospitals (GMHs), predominantly in a few specialty areas such as cardiac disease and surgical fields. Many specialty hospitals advertise high rates of patient satisfaction.[7, 8, 9, 10, 11] However, specialty hospitals differ from GMHs in significant ways. Patients at specialty hospitals may be less severely ill[10, 12] and may have more generous insurance coverage.[13] Many specialty hospitals do not have an emergency department (ED), and their outcomes may reflect care of relatively stable patients.[14] A significant number of the specialty hospitals are physician‐owned, which may provide an opportunity for physicians to deliver more patient‐focused healthcare.[14] It is also thought that specialty hospitals can provide high‐quality care by designing their facilities and service structure entirely to meet the needs of a narrow set of medical conditions.

HCAHPS survey results provide an opportunity to compare satisfaction scores among various types of hospitals. We analyzed national HCAHPS data to compare satisfaction scores of specialty hospitals and GMHs and identify factors that may be responsible for this difference.

METHODS

This was a cross‐sectional analysis of national HCAHPS survey data. The methods for administration and reporting of the HCAHPS survey have been described.[15] HCAHPS patient satisfaction data and hospital characteristics, such as location, presence of an ED, and for‐profit status, were obtained from Hospital Compare database. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16]

For this study, we defined specialty hospitals as acute‐care hospitals that predominantly provide care in a medical or surgical specialty and do not provide care to general medical patients. Based on this definition, specialty hospitals include cardiac hospitals, orthopedic and spine hospitals, oncology hospitals, and hospitals providing multispecialty surgical and procedure‐based services. Children's hospitals, long‐term acute‐care hospitals, and psychiatry hospitals were excluded.

Specialty hospitals were identified using hospital name searches in the HCAHPS database, the American Hospital Association 2013 Annual Survey, the Physician Hospital Association hospitals directory, and through contact with experts. The specialty hospital status of hospitals was further confirmed by checking hospital websites or by directly contacting the hospital.

We analyzed 3‐year HCAHPS patient satisfaction data that included the reporting period from July 2007 to June 2010. HCAHPS data are reported for 12‐month periods at a time. Hospital information, such as address, presence of an ED, and for‐profit status were obtained from the CMS Hospital Compare 2010 dataset. Teaching hospital status was identified using the CMS 2013 Open Payment teaching hospital listing.[16] For the purpose of this study, scores on the HCAHPS survey item definitely recommend the hospital was considered to represent overall satisfaction for the hospital. This is consistent with use of this measure in other sectors in the service industry.[17, 18] Other survey items were considered subdomains of satisfaction. For each hospital, the simple mean of satisfaction scores for overall satisfaction and each of the subdomains for the three 12‐month periods was calculated. Data were summarized using frequencies and meanstandard deviation. The primary dependent variable was overall satisfaction. The main independent variables were specialty hospital status (yes or no), teaching hospital status (yes or no), for‐profit status (yes or no), and the presence of an ED (yes or no). Multiple linear regression analysis was used to adjust for the above‐noted independent variables. A P value<0.05 was considered significant. All analyses were performed on Stata 10.1 IC (StataCorp, College Station, TX).

RESULTS

We identified 188 specialty hospitals and 4638 GMHs within the HCAHPS dataset. Fewer specialty hospitals had emergency care services when compared with GMHs (53.2% for specialty hospitals vs 93.6% for GMHs, P<0.0001), and 47.9% of all specialty hospitals were in states that do not require a Certificate of Need, whereas only 25% of all GMHs were present in these states. For example, Texas, which has 7.2% of all GMHs across the nation, has 24.7% of all specialty hospitals. As compared to GMHs, a majority of specialty hospitals were for profit (14.5% vs 66.9%).

In unadjusted analyses, specialty hospitals had significantly higher patient satisfaction scores compared with GMHs. Overall satisfaction, as measured by the proportion of patients that will definitely recommend that hospital, was 18.8% higher for specialty hospitals than GMHs (86.6% vs 67.8%, P<0.0001). This was also true for subdomains of satisfaction including physician communication, nursing communication, and cleanliness (Table 1).

We next examined the effect of survey response rate. The survey response rate for specialty hospitals was on average 17.4 percentage points higher than that of GMHs (49.6% vs 32.2%, P<0.0001). When adjusted for survey response rate, the difference in overall satisfaction for specialty hospitals was reduced to 8.6% (6.7%10.5%, P<0.0001). Similarly, the differences in score for subdomains of satisfaction were more modest when adjusted for higher survey response rate. In the multiple regression models, specialty hospital status, survey response rate, for‐profit status, and the presence of an ED were independently associated with higher overall satisfaction, whereas teaching hospital status was not associated with overall satisfaction. Addition of for‐profit status and presence of an ED in the regression model did not change our results. Further, the satisfaction subdomain scores for specialty hospitals remained significantly higher than for GMHs in the regression models (Table 1).

DISCUSSION

In this national study, we found that specialty hospitals had significantly higher overall satisfaction scores on the HCAHPS satisfaction survey. Similarly, significantly higher satisfaction was noted across all the satisfaction subdomains. We found that a large proportion of the difference between specialty hospitals and GMHs in overall satisfaction and subdomains of satisfaction could be explained by a higher survey response rate in specialty hospitals. After adjusting for survey response rate, the differences were comparatively modest, although remained statistically significant. Adjustment for additional confounding variables did not change our results.

Studies have shown that specialty hospitals, when compared to GMHs, may treat more patients in their area of specialization, care for fewer sick and Medicaid patients, have greater physician ownership, and are less likely to have ED services.[11, 12, 13, 14] Two small studies comparing specialty hospitals to GMHs suggest that higher satisfaction with specialty hospitals was attributable to the presence of private rooms, quiet environment, accommodation for family members, and accessible, attentive, and well‐trained nursing staff.[10, 11] Although our analysis did not account for various other hospital and patient characteristics, we expect that these factors likely play a significant role in the observed differences in patient satisfaction.

Survey response rate can be an important determinant of the validity of survey results, and a response rate >70% is often considered desirable.[19, 20] However, the mean survey response rate for the HCAHPS survey was only 32.8% for all hospitals during the survey period. In the outpatient setting, a higher survey response rate has been shown to be associated with higher satisfaction rates.[21] In the hospital setting, a randomized study of a HCAHPS survey for 45 hospitals found that patient mix explained the nonresponse bias. However, this study did not examine the roles of severity of illness or insurance status, which may account for the differences in satisfaction seen between specialty hospitals and GMHs.[22] In contrast, we found that in the hospital setting, higher survey response rate was associated with higher patient satisfaction scores.

Our study has some limitations. First, it was not possible to determine from the dataset whether higher response rate is a result of differences in the patient population characteristics between specialty hospitals and GMHs or it represents the association between higher satisfaction and higher response rate noted by other investigators. Although we used various resources to identify all specialty hospitals, we may have missed some or misclassified others due to lack of a standardized definition.[10, 12, 13] However, the total number of specialty hospitals and their distribution across various states in the current study are consistent with previous studies, supporting our belief that few, if any, hospitals were misclassified.[13]

In summary, we found significant difference in satisfaction rates reported on HCAHPS in a national study of patients attending specialty hospitals versus GMHs. However, the observed differences in satisfaction scores were sensitive to differences in survey response rates among hospitals. Teaching hospital status, for‐profit status, and the presence of an ED did not appear to further explain the differences. Additional studies incorporating other hospital and patient characteristics are needed to fully understand factors associated with differences in the observed patient satisfaction between specialty hospitals and GMHs. Additionally, strategies to increase survey HCAHPS response rates should be a priority.