Patient Experience

Patrick P. Kneeland, MD

KEYWORDS
 Patient experience  Patient satisfaction  Provider experience  HCAHPS
 Hospitalist  Health care value

HOSPITAL MEDICINE CLINICS CHECKLIST

1. Consider patient experience, quality of care, and patient safety as interdepen-

dent elements of high-value care.
2. Seek enhanced understanding of specific drivers of patient experience.
3. Become familiar with the Hospital Consumer Assessment of Healthcare Pro-
viders and Systems (HCAHPS) survey.
4. Seek to develop a high-yield patient-physician communication skill set.
5. Seek actionable data around patient experience and embrace constructive
feedback, including through peer coaching.
6. Embrace, optimize, and innovate around the use of physical tools for enhanced
patient experience, such as whiteboards and face cards.
7. Embrace, optimize, and innovate around the use of digital tools for enhanced
patient experience, including through transparency of the electronic health re-
cord and other forms of digital access to care.
8. Because provider experience and patient experience are interdependent, lead
efforts to improve systems of care, including efforts that streamline work flow
and improve the working lives of hospitalists.
9. Realize that an enhanced patient experience seems to have less to do with
making patients happy or providing luxurious amenities, and more to do with
communication effectiveness and coordination of the health care team.

KEY PRINCIPLES

What is patient experience?

In recent years, the concept of patient experience has taken a prominent position in
the health care improvement discourse. This concept has manifested formally as a

Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine,

University of Colorado Anschutz Medical Campus, Leprino Building, 4th Floor, Mailstop
F-782, 12401 East 17th Avenue, Aurora, CO 80045, USA
E-mail address: Patrick.Kneeland@ucdenver.edu

Hosp Med Clin 5 (2016) 137–151

http://dx.doi.org/10.1016/j.ehmc.2015.08.011
2211-5943/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
138 Kneeland

driver of national health care policy in the United States and other countries, and has
driven hospitals and health care systems to develop infrastructures for improving how
patients experience health care.1–3 In some cases, hospitals and health systems have
framed their entire health care delivery enterprise around improving patient experi-
ence, and there has been an increase in the number of formal patient experience lead-
ership roles, including chief experience officers, at many institutions.4–6

Defining Patient Experience

Tantamount to the patient experience discourse has been an active dialogue among
patient advocates, providers, administrators, and payers as these stakeholders seek
to better understand the essential factors affecting the way patients experience health
care.7 The Beryl Institute proposes a commonly definition of patient experience as
“The sum of all interactions, shaped by an organization’s culture, that influence patient
perceptions, across the continuum of care.”8 Several other definitions of patient expe-
rience exist, all of which contribute to an ongoing exploration of what experience
means in health care (Table 1). The Society of Hospital Medicine’s Patient Experience
Committee recently approved a working definition as “Everything we say and do that
affects our patients’ thoughts, feelings and well-being.”

Frameworks for Patient Experience

In addition to definitions of patient experience, multiple frameworks have been put
forth to further illuminate elements of patient experience. These frameworks range
from the Picker Institute’s 8 components of patient-centered care9; to Don Ber-
wick’s14 3-pronged focus on science, access, and relationships; to Tom Lee’s10
straightforward goal to relieve suffering and bring peace of mind to patients and their
families.

What is the relationship between patient experience and value in health care?

Regardless of the exact patient experience definition or framework under consider-

ation, the pursuit of an optimized patient experience seems to be a worthy cause. Be-
sides the ethical and moral imperative implicit in improving the patient experience,
much of the focus on patient experience has stemmed from a renewed evaluation
of health care economics and value.
Greatly increased health care costs in recent decades have led to higher scrutiny by
patients, payers, and policy makers of the relationship between cost and quality of
health care delivery. The value equation in health care is complex, with numerous
stakeholders and often conflicting goals in play, including quality, safety, profitability,
cost-effectiveness, and patient satisfaction. It has been argued that the key elements
of increased health care value are quality (reliable, evidence-based medicine), safety
(preventing avoidable harm to patients), patient experience (as defined earlier), and
lower cost (or less waste).15 The Institute for Healthcare Improvement (IHI) has similarly
framed health care value in its Triple Aim as a combination of (1) decreased per capita
cost, (2) increased population health, and (3) enhanced patient experience of care.16
Michael Porter17 argues that patient experience, defined broadly, should be at the
center of any discussion of health care value: “Value should always be defined around
the customer, and in a well-functioning health care system, the creation of value for
patients should determine the rewards for all other actors in the system.”17
Importantly, there is significant evidence to suggest that the drivers of health care
value (quality, safety, and experience) are interdependent factors, rather than ex-
clusive elements (discussed later). Furthermore, with increased formal (ie,
 Patient Experience 139

Table 1
Definitions and frameworks for patient experience

Example Definitions of Patient Experience Source

The sum of all interactions, shaped by an organization’s The Beryl Institute
culture, that influence patient perceptions, across the
continuum of care
Everything clinicians say and do that affects their patients’ The Society of Hospital
thoughts, feelings, and well-being Medicine, Patient
Experience Committee
working definition

Example Frameworks for Describing Patient Experience Source

Three key components of patient experience: (1) access to Don Berwick
appropriate care, (2) science (reliable evidence-based care),
(3) relationships between care providers and patients
The extent to which health care providers are able to reduce Tom Lee, CMO of Press
preventable suffering and bring patients and their families Ganey
peace of mind
Five core drivers of patient and family experience in hospitals: IHI
(1) leadership; (2) staff hearts and minds; (3) respectful
partnership, including shared decision making with
patients; (4) reliable care; and (5) evidence-based care
Eight elements of optimized patient experience: (1) effective Picker Institute
treatment delivered by staff that patients can trust; (2)
involvement in decisions and respect for patients’
preferences; (3) fast access to reliable health care advice; (4)
clear, comprehensible information and support for self-care;
(5) physical comfort and a clean, safe environment; (6)
empathy and emotional support; (7) involvement of family
and friends; and (8) continuity of care and smooth
transitions
Seven core elements for optimized patient experience: (1) Warwick Framework
patients as active participants in care, (2) responsiveness of
services, (3) an individualized approach, (4) lived experience,
(5) continuity of care and relationships, (6) communication,
(7) information and support
Six core elements for optimized patient experience: (1) Institute of Medicine
compassion, empathy, and responsiveness; (2) coordination
and integration of care; (3) information and
communication; (4) physical comfort; (5) emotional support
and relief of anxiety; (6) involvement of family and friends

Abbreviations: CMO, Chief Medical Officer; IHI, Institute for Healthcare Improvement.
Adapted from Refs.1,8–13

hospitalcompare.hhs.gov) and informal (ie, yelp.com) public reporting of quality mea-

sures, including patient experience data, patients will have the ability to develop their
own relative value assessments to inform where to seek care18 (Fig. 1). With regard to
hospital revenue, this has led to a fundamental shift in how hospitals view market-
share strategy, from one focused on attracting physician groups to one of attracting
patients directly.19
It is this discourse that has driven policy around Medicare reimbursement and
value-based purchasing, and it is likely that private payers and patients alike will
increasingly demand evidence of value, including patient experience20 (Fig. 2).
140 Kneeland

Fig. 1. Public reporting of Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) data. (From Medicare.gov. Hospital Compare. Available at: www.
hospitalcompare.hhs.gov. Accessed August 20, 2015; with permission.)

Fig. 2. Multiple stakeholders focus on value in health care.

 Patient Experience 141

The direct relationship between patient-centeredness and cost needs further explo-
ration. One small study of 200 patients in southeastern Michigan suggested that
patient-centered care, measured by patient perceptions in surveys, had better clinical
outcomes, but at a higher cost.21 A second study associated higher patient satisfac-
tion with less emergency department use, but higher overall health care expenditure
and increased mortality.22
At the same time, some innovative models, such as the Group Health Medical Home,
have shown that patient-centered systems can align impressively with improved
outcomes, and cost.23,24 In addition, there is evidence that more efficient hospitals
have higher patient satisfaction scores and hospitalist models have been associated
with decreased resource use without compromising patient experience.25,26

What is the Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey? How does it relate to value-based purchasing and the Medicare
star rating?

Many US hospitals have collected patient satisfaction data for at least the past
30 years.27 However, only recently have policy decisions promoted the use of a uni-
form evaluation instrument to compare hospitals directly. The HCAHPS survey is a
national survey of patient self-reported experiences with inpatient care.28 HCAHPS
contains 32 items with 8 dimensions and is administered between 48 hours and
6 weeks after hospital discharge by one of 3 methods: telephone, mail, or interactive
voice recognition. Hospitals are allowed to determine how many patients to survey but
must target a minimum of 300 returned surveys annually. The HCAHPS instrument
was developed in the early 2000s and was made available to hospitals on a voluntary
basis in 2006. In 2008, HCAHPS survey implementation was first linked to Centers for
Medicare and Medicaid Services (CMS) reimbursement and has been a staple of the
CMS inpatient value-based purchasing rule ever since.29 For the fiscal year 2016,
1.75% of hospitals’ diagnosis-related group (DRG)-related reimbursement payments
were linked to performance on value-based purchasing measures, with 25% of that
reimbursement linked directly to performance on HCAHPS. HCAHPS data are simi-
larly weighted at 25% of the value-based purchasing composite for the 2017 fiscal
year (Box 1, Tables 2 and 3).
In 2008, acute care hospitals that accepted Medicare payments were required not
only to implement the HCAHPS survey for their population but also to report the data
publicly on the CMS Hospital Compare Web site (hospitalcompare.hhs.gov) with other
publicly reported quality indicators. In April 2015, Medicare released star ratings for
patient satisfaction on the Hospital Compare Web site for the first time. These star rat-
ings are not linked directly to value-based purchasing reimbursement but are intended
to allow consumers to more easily evaluate comparative satisfaction data. The top
performing hospitals receive 5 stars and the worst performing 1 star according to
this schema, with fewer hospitals earning 5 and 1 stars relative to those earning 2,
3, and 4 stars.30

What HCAHPS dimensions do hospitalists affect most?

Of the 8 HCAHPS domains, it seems logical that the most likely to be affected by hos-
pitalists are the patients’ perceptions of communication with doctors, communication
about medicines, discharge information, and overall hospital rating. Of note, patient
experience with hospital care seems to be affected more by hospitalists than by emer-
gency medicine physicians.31 However, the relative influence of hospitalists,
142 Kneeland

Box 1
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions
most likely to be directly affected by hospitalists

Communication with Doctors dimension

During this hospital stay, how often did doctors treat you with courtesy and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you could understand?
Other questions
During this hospital stay, did doctors, nurses, or other hospital staff talk with you about
whether you would have the help you needed when you left the hospital?
During this hospital stay, did you get information in writing about what symptoms or health
problems to look out for after you left the hospital?
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital
possible, what number would you use to rate this hospital during your stay?
Would you recommend this hospital to your friends and family?
During this hospital stay, staff took my preferences and those of my family or caregiver into
account in deciding what my health care needs would be when I left.
When I left the hospital, I had a good understanding of the things I was responsible for in
managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.

specialists, nurses, other allied health professionals, staff, and environmental factors
on each HCAHPS domain needs further exploration.

What is the relationship between patient experience and health care quality?
Considerable debate persists around the question of whether patient experience is a
valid measure of quality, and whether patient experience positively affects other

Table 2
Patient experience as a proportion of CMS hospital reimbursement for value-based
purchasing incentive

Relative Domain Weight (%) for Hospital Payments

Each Fiscal Year
Value-based purchasing domain 2017 2016 2015 2014 2013
Patient experience 25 25 30 30 30
Quality of care (processes) 5 10 20 45 70
Quality of care (outcomes) 25 40 30 25 —
Efficiency 25 25 20 — —
Patient safety 20 — — — —
Percentage of Hospital payment 2.00 1.75 1.50 1.25 1.00
withheld

Data from Centers for Medicare and Medicaid Services. Hospital value-based purchasing. Available
at: https://www.cms.gov/Medicare/Quality-lnitiatives-Patient-Assessment-lnstruments/hospital-
value-based-purchasing/index.html?redirect5/Hospital-Value-Based-Purchasing/. Accessed August
20, 2015.
 Patient Experience 143

Table 3
The 8 HCAHPS dimensions

Communication with doctors

Overall rating of hospital
Discharge information Increasing likelihood
Communication about medicines of direct hospitalist
Pain management impact on dimension
Communication with nurses
Responsiveness of hospital staff
Hospital cleanliness and quietness

elements of high-quality care.32,33 Skeptics argue that increased focus on patient

satisfaction, for example, may occur at the expense of other important outcomes.34
At the same time, a recent systematic literature review shows a strong positive cor-
relation between patient experience and several domains of clinical quality, including
health outcomes, adherence to treatments, accessing preventative care, and patient
safety.35 The investigators suggest that “The inclusion of patient experience as one of
the pillars of quality is partly justified on the grounds that patient experience data,
robustly collected and analyzed, may help highlight strengths and weaknesses in
effectiveness and safety and that focusing on improving patient experience will in-
crease the likelihood of improvements in the other two domains.”
In the hospital setting, higher rates of overall patient satisfaction correlate strongly
with adherence to evidence-based guidelines and inpatient mortality from myocardial
infarction.36 Jha and colleagues37 found that hospitals with high levels of patient satis-
faction showed higher quality of care for acute myocardial infarction and pneumonia.
In addition, higher overall patient satisfaction scores seem to correlate with lower
30-day readmission rates for patients admitted with myocardial infarction, pneumonia,
and heart failure even when adjusted for hospital adherence to quality-of-care
guidelines.38

What is the relationship between patient experience and provider experience?

Recent studies have shown that nearly half of all US physicians experience symptoms
of burnout including “loss of enthusiasm for work (emotional exhaustion), feelings of
cynicism (depersonalization), and a low sense of personal accomplishment.”39
Burnout is significantly prevalent among general internists, ranking second only to
emergency medicine providers among all specialties.
Research indicates that lack of provider satisfaction and increased burnout is linked
to several important quality indicators, including patient satisfaction.40,41 As such, it
has been proposed that physician wellness be more deliberately incorporated into a
holistic approach to improving quality of care.42
The current health care landscape has added several pressures on providers to
optimize the quality of care they provide for patients, often in the absence of adequate
infrastructure or resources. In response to those pressures, Bodenheimer and Sin-
sky43 proposed that attention to the provider experience (ie, “improving the work
life of health care providers”) is essential to optimizing health care quality and value.43
They propose that the IHI’s Triple Aim for optimizing health system performance be
expanded to include a fourth aim: care for the provider (Fig. 3). The sources for
much of the dissatisfaction seen among providers may be related to provider percep-
tion that they are not able to provide high-quality care,44 increased administrative
144 Kneeland

Fig. 3. The quadruple AIM.

tasks that replace time with patients (including through inefficient electronic health re-
cords), and the burden of working to achieve the Triple Aim without adequate sup-
port.45,46 The call for a Quadruple Aim sensibility has been echoed elsewhere as a
key element to successful health care value and patient experience enhancement
strategy.47 Patient experience innovation champions have even proposed that
“restoring joy to the practice of medicine”48 for providers is at the center of meaningful
improvement of patient experience.48

GUIDELINES FOR PRACTICE

Understanding what Patients Care About Most
A critical question that hospitalists must consider when evaluating practices that may
improve patient experience concerns the experience factors that are most relevant to
patients and their families? Although the weight of various factors is likely specific to
individuals and related to several other determinants, such as the type of illness being
addressed, there seem to be some features of the factors that patients prioritize that
can be generalized. For example, qualitative analysis has shown that positive experi-
ences with access to care, communication, provider personality/demeanor, provider
competence, provider thoroughness, provider continuity, facilities, and follow-up/
coordination of care all correlate with overall positive health care experience.49 Other
studies suggest that the overall satisfaction of patients seems to be linked to patients’
perceptions of skill and the responsiveness of nurses and providers.36 Press Ganey
analyzed patient satisfaction for 1 million patients and found that the most likely deter-
minants of the willingness to recommend care to others were (1) confidence in the pro-
vider (“Your confidence in this care provider”), (2) coordination of care (“How well the
staff worked together to care for you”), (3) concern for worries (“Concern the care pro-
vider showed for your questions or worries”), (4) listening (“During your most recent
visit, did this provider listen carefully to you?”), and (5) courtesy (“Friendliness/cour-
tesy of the care provider”).50 Within the HCAHPS survey domains, the data present
a dilemma for hospitalists, suggesting a hierarchy in terms of correlation with overall
satisfaction in the hospital with communication with nurses, pain management, and
timeliness of assistance at the top followed by explanation of medications and
communication with doctors.38
Regarding hospitalists specifically, key factors affecting patient experience of care
include the opportunity for patients to have all of their questions answered, complete
 Patient Experience 145

discussions around medication side effects, and the ability of physicians to show
listening and form personal connections with patients.51
Notably, a preponderance of data indicate that, ultimately, an enhanced patient
experience entails more than making patients happy or providing luxurious amenities,
and that efforts around communication effectiveness and coordination of the health
care team remain critical.50 Developing strategies beyond superficial survey data for
continuing to understand the elements that are most important to patients in a given
clinical care setting is imperative for improving the patient experience.52
Enhancing the Patient Communication Toolkit for Providers
Effective provider communication is seen as critical for patient-centered care and is a
key determinant of the quality of patient experience.31,53,54 Although communication
skills have been increasingly taught in medical school curricula, ongoing professional
development of physicians in effective communication past medical school is uncom-
mon. In their efforts to overhaul the way patients experience care, physician leaders at
The Cleveland Clinic have implemented a full day of communication skills training for
all of its several thousand physicians. Based on a specific skills-based framework,55
initial analysis of 900 physicians who have gone through the training has shown a pos-
itive impact on patient satisfaction survey results, as well as decreased provider
burnout and increased provider empathy, as measured by the Maslach Burnout Inven-
tory and Jefferson Empathy Scale, respectively.56 Effective skill set development may
not only address patient experience but also provider experience. A single study of the
impact of communication training for hospitalists on HCAHPS scores showed a trend
(although not statistical significance) toward improvement.57
Despite their simplicity, etiquette-based communication techniques, such as clini-
cians introducing themselves, explaining their roles in the patient’s care, sitting
down when talking to patients, touching the patient, and asking open-ended ques-
tions, are underused in the inpatient setting.58 These techniques represent areas of
actionable improvement for hospitalists. For example, providers sitting during patient
interviews enhance patient perception of time spent with the provider,59 which seems
to enhance patient satisfaction by showing elements of empathy and
compassion.60,61
Several models for effective communication exist,62–66 but more research is needed
into the elements of high-yield professional development around communication. In
spite of this, it is likely that the development of such skills for hospitalists will be critical
for enhanced patient experience.
Other Tools to Enhance Patient Experience
Beyond the development of communication skill sets, several physical tools have
shown promise in promoting patient-centered communication by hospitalists in the
inpatient setting.
Whiteboards
Studies have shown that hospitalized patients frequently lack understanding of their
plan of care.67 When used effectively, whiteboards in patient rooms have been shown
to significantly improve patient satisfaction with nurse communication, physician
communication, and involvement in decision-making care domains.68,69
Face cards
As few as 13% of patients in hospitals are able to identify one of their physi-
cians.67,70,71 It is difficult to imagine that patients feel a personal connection with, or
have high degree of confidence in, physicians if they cannot identify them. Patients
146 Kneeland

who receive face cards are more likely to be able to identify their physicians,70,72
although the link between face cards and patient experience needs further evaluation.
It is likely that face cards would have the highest impact if paired with specific skill set
development around etiquette-based communication and used to make a personal
connection with patients and their families.

Digital tools
Several information technology platforms have been designed to affect the way pa-
tients interface with the health care system, and it is likely that digital solutions will
continue to disrupt traditional modes of patient-physician interaction. For example,
widespread adoption of electronic health records has facilitated parallel development
of digital patient portals, enabling patients to engage their physicians and health care
records in new ways.73 The OpenNotes initiative has promoted full transparency of the
medical record to patients and may fundamentally redefine how patients experience
care.74 Although initially gaining momentum in outpatient primary care, it is certain
that hospitals will increasingly follow suit; a transition in which hospitalists should pro-
actively engage.75,76 Early findings related to patient experience with OpenNotes are
intriguing, with more than 80% of patients reading their notes, more than 70% saying
they thought that they had a better understanding of their conditions, and more than
60% reporting better therapeutic adherence, without reporting increased anxiety,
confusion, or offended feelings.77
As physicians continue to determine how new asynchronous communication stra-
tegies (such as text messaging) are most effectively integrated into work flows,78 it
is likely that patients will increasingly look to the modes of communication that are
common outside of health care.79 These technologies, and hospitalists’ willingness
to engage with them proactively, will almost certainly continue to inform how patients
optimally experience inpatient care.

Seeking Actionable Feedback

Measuring and analyzing meaningful and outcomes-based data are at the core of
improving the quality of care in any domain. A recent survey of hospitalists suggested
that although 89% thought that actionable feedback on communication with patients
is critical to improvement in their practice, only 18% had received such feedback in the
past 6 months.80 Banka and colleagues81 found that, when paired with specific and
provider-attributable data, discussions of best practice around patient experience
can improve patients’ experience of care. Moreover, many effective interventions
around communication have included direct feedback.82 In many hospitals, HCAHPS
data have often been the domain of service excellence and not always transparent to
physician groups. This finding is changing as hospitals increasingly engage physician
leaders to help improve patient experience. Beyond transparency of the data, another
key limitation of HCAHPS data in many hospitals is the inability to attribute the data to
individual physicians in a way that promotes learning and improvement. In some
cases, sample size is too small for individual physicians to be meaningful; in others,
attribution is limited by the electronic health record or turnover of providers during a
patient stay. Tools have been proposed to provide hospitalists with specific and
actionable feedback.71 Hospitalists should advocate within their hospital systems
and with survey vendors for increased capacity for such data.
In addition to seeking actionable data, hospitalists should remain open to the possi-
bility of peer-to-peer coaching around patient experience. Although time-intensive and
resource-intensive, real-time coaching around competencies such as communication is
likely to provide high-yield feedback that is not accessible through data review alone.83
 Patient Experience 147

Taking a Leadership Role in Health Systems Redesign in Hospitals

Hospitalists as individuals can almost certainly affect how patients experience health
care. At the same time, the interactions and complexities that contribute to the overall
care experience dictate that the most effective experience enhancement strategies
will address the interactive components present in hospital care. As such, hospitalists
will be called on to contribute to quality improvement activities that are associated
with satisfaction and outcomes.32 For example, Stein and colleagues84 led the devel-
opment of inpatient accountable care units that are built around (1) geographically
cohorted unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-
level performance reporting, and (4) unit-level nurse and physician dyad leadership re-
sponsibilities. Central to these types of quality improvement efforts will be (1) the use
of the patient voice and experience data to prioritize improvement targets,85,86 and (2)
the deliberate integration of experience mapping into process redesign that reflects
the patient pathway through care delivery87 as well as provider work flow
experience.88

REFERENCES

1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing

the quality chasm. National Academies Press; 2001.
2. VanLare JM, Conway PH. Value-based purchasing — national programs to move
from volume to value. N Engl J Med 2012;367(4):292–5.
3. Black N, Jenkinson C. Measuring patients’ experiences and outcomes. BMJ
2009;339:b2495.
4. Merlino JI, Raman A. Health care’s service fanatics. Harv Bus Rev 2013;91(5):
108–16, 150.
5. cxo-report-reg-lp.html. solutionsvoceracom. Available at: http://solutions.vocera.
com/cxo-report-reg-lp.html. Accessed May 30, 2015.
6. sharp-experience.cfm. sharpcom. Available at: http://www.sharp.com/choose-
sharp/sharp-experience.cfm. Accessed May 30, 2015.
7. Naidu A. Factors affecting patient satisfaction and healthcare quality. Int J Health
Care Qual Assur 2013;22(4):366–81.
8. ?page5definingpatientexp. theberylinstituteorg. Available at: http://www.
theberylinstitute.org/?page5definingpatientexp. Accessed June 14, 2015.
9. The Picker Institute. Available at: http://www.pickerinstitute.org. Accessed May
30, 2015.
10. Lee TH. The word that shall not be spoken. N Engl J Med 2013;369(19):1777–9.
11. berwick_escapefire_563.pdf. commonwealthfundorg. Available at: http://www.
commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf. Accessed June
15, 2015.
12. Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and
Family Experience of Inpatient Hospital Care. Available at: www.ihi.org. Ac-
cessed June 14, 2015.
13. Staniszewska S, Boardman F, Gunn L, et al. The Warwick Patient Experiences
Framework: patient-based evidence in clinical guidelines. Int J Qual Health
Care 2014;26(2):151–7.
14. Berwick DM. Escape fire: lessons for the future of health care. 2002.
15. How UCSF is solving the quality cost and value equation. Available at: thehealth-
careblogcom. http://dx.doi.org/10.1111/1468-0009.00195/abstract. Accessed
June 14, 2015.
148 Kneeland

16. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost.
Health Aff (Millwood) 2008;27(3):759–69.
17. Porter ME. What is value in health care? N Engl J Med 2010;363(26):
2477–81.
18. Greaves F, Ramirez-Cano D, Millett C, et al. Harnessing the cloud of patient expe-
rience: using social media to detect poor quality healthcare. Qual Saf Health Care
2013;22(3):251–5.
19. Goldman DP, Vaiana M, Romley JA. The emerging importance of patient ame-
nities in hospital care. N Engl J Med 2010;363(23):2185–7.
20. Bush H. Doubling down on the patient experience. Hosp Health Netw 2011;
85(12):22–5, 1.
21. Bechel D, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J
Qual Improv 2000;26(7):400–9.
22. Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction: a national study
of patient satisfaction, health care utilization, expenditures, and mortality. Arch
Intern Med 2012;172(5):405–11.
23. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year
two: cost savings, higher patient satisfaction, and less burnout for providers.
Health Aff (Millwood) 2010;29(5):835–43.
24. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and
lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr
Soc 2007;55(7):993–1000.
25. Wachter RM, Katz P, Showstack J, et al. Reorganizing an academic medical ser-
vice: impact on cost, quality, patient satisfaction, and education. JAMA 1998;
279(19):1560–5.
26. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, out-
comes, and patient satisfaction in a rural health system. Am J Med 2000;
108(8):621–6.
27. Siegrist RB. Patient satisfaction: history, myths, and misperceptions. Virtual
Mentor 2013;15(11):982–7.
28. The HCAHPS Survey - frequently asked questions. Available at: http://www.cms.
gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQuality
Inits/Downloads/HospitalHCAHPSFactSheet.pdf.
29. Giordano LA, Elliott MN, Goldstein E, et al. Development, implementation, and
public reporting of the HCAHPS survey. Med Care Res Rev 2009;67(1):27–37.
30. HCAHPS_fact_sheet_June_2015.pdf. hcahpsonlineorg. Available at: http://www.
hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf. Accessed June 3,
2015.
31. Wild DMG, Kwon N, Dutta S, et al. Who’s behind an HCAHPS score? Jt Comm J
Qual Patient Saf 2011;37(10):461–8.
32. Manary MP, Boulding W, Staelin R, et al. The patient experience and health out-
comes. N Engl J Med 2013;368(3):201–3.
33. Farley H, Enguidanos ER, Coletti CM, et al. Patient satisfaction surveys and qual-
ity of care: an information paper. Ann Emerg Med 2014;64(4):351–7.
34. Robbins A. The problem with satisfied patients. The Atlantic 2015.
35. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness. BMJ Open 2013;3(1).
http://dx.doi.org/10.1136/bmjopen-2012-001570.
36. Glickman SW, Boulding W, Manary M, et al. Patient satisfaction and its relation-
ship with clinical quality and inpatient mortality in acute myocardial infarction.
Circ Cardiovasc Qual Outcomes 2010;3(2):188–95.
 Patient Experience 149

37. Jha AK, Orav EJ, Zheng J, et al. Patients’ perception of hospital care in the United
States. N Engl J Med 2008;359(18):1921–31.
38. Boulding W, Glickman SW, Manary MP, et al. Relationship between patient satis-
faction with inpatient care and hospital readmission within 30 days. Am J Manag
Care 2011;17(1):41–8.
39. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life bal-
ance among US physicians relative to the general US population. Arch Intern
Med 2012;172(18):1377–85.
40. Williams ES, Manwell LB, Konrad TR, et al. The relationship of organizational cul-
ture, stress, satisfaction, and burnout with physician-reported error and subopti-
mal patient care: Results from the MEMO study. Health Care Manage Rev 2007;
32(3):203–12.
41. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general in-
ternists associated with patient satisfaction? J Gen Intern Med 2000;15(2):122–8.
42. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indica-
tor. Lancet 2009;374(9702):1714–21.
43. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient re-
quires care of the provider. Ann Fam Med 2014;12(6):573–6.
44. Friedberg MW, Chen PG, Van Busum KR, et al. RAND RESEARCH REPORT: fac-
tors affecting physician professional satisfaction and their implications for patient
care. Health Systems; 2013.
45. Lewis SE, Nocon RS, Tang H, et al. Patient-centered medical home character-
istics and staff morale in safety net clinics. Arch Intern Med 2012;172(1):
23–31.
46. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician
stress in primary care: results from the MEMO Study. J Am Med Inform Assoc
2014;21(e1):e100–6.
47. Spiegelman P, Berrett B. Patients come second. Incorporated 500 Press; 2013.
48. triple-aim-nurse-doctor-burnout-article-duffy. hhnmagcom. Available at: http://
www.hhnmag.com/Daily/2015/May/triple-aim-nurse-doctor-burnout-article-duffy.
Accessed June 3, 2015.
49. Anderson R, Barbara A, Feldman S. What patients want: a content analysis of key
qualities that influence patient satisfaction. J Med Pract Manage 2007;22(5):255–61.
50. Protecting market share in the era of reform. 2013. Available at: http://www.
physicianstrategygroup.com/wp-content/uploads/PerfInsights_PatientLoyalty_
Nov2013.pdf.
51. Blanden AR, Rohr RE. Cognitive interview techniques reveal specific behaviors
and issues that could affect patient satisfaction relative to hospitalists. J Hosp
Med 2009;4(9):E1–6.
52. Merlino JI, Raman A. Understanding the drivers of the patient experience.
2013. Available at: https://hbr.org/2013/09/understanding-the-drivers-of-the-
patient-experience/. Accessed June 14, 2015.
53. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills
for patient-centered care. Health Aff (Millwood) 2010;29(7):1310–8.
54. Bartlett EE, Grayson M, Barker R, et al. The effects of physician communications skills
on patient satisfaction; recall, and adherence. J Chronic Dis 1984;37(9–10):755–64.
55. Windover AK, Boissy A, Rice TW. The REDE model of healthcare communication:
optimizing relationship as a therapeutic agent. Journal of Patient Experience 2014.
56. Boissy A, Velez V, Harry L. Case studies in improving patient experience. Pre-
sented at Society of Hospital Medicine, National Conference, Washington D.C.
March 2015.
150 Kneeland

57. O’Leary KJ, Darling TA, Rauworth J, et al. Impact of hospitalist communication-
skills training on patient-satisfaction scores. J Hosp Med 2013;8(6):315–20.
58. Block L, Hutzler L, Habicht R, et al. Do internal medicine interns practice
etiquette-based communication? A critical look at the inpatient encounter.
J Hosp Med 2013;8(11):631–4.
59. Swayden KJ, Anderson KK, Connelly LM, et al. Effect of sitting vs. standing on
perception of provider time at bedside: a pilot study. Patient Educ Couns 2012;
86(2):166–71.
60. Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing
during inpatient oncology consultations: patients’ preference and perception of
compassion and duration. A randomized controlled trial. J Pain Symptom
Manage 2005;29(5):489–97.
61. Rothberg MB, Steele JR, Wheeler J, et al. The relationship between time spent
communicating and communication outcomes on a hospital medicine service.
J Gen Intern Med 2012;27(2):185–9.
62. Makoul G. The SEGUE Framework for teaching and assessing communication
skills. Patient Educ Couns 2001;45(1):23–34.
63. Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits
model. J Med Pract Manage 2001;16(4):184–91.
64. Makoul G. Essential elements of communication in medical encounters: the Kala-
mazoo consensus statement. Acad Med 2001;76:390–3.
65. Fortin AH, Dwamena FC, Frankel RM, et al. Smith’s patient centered interviewing:
an evidence-based method. 3rd edition. McGraw-Hill Professional; 2012.
66. Boyle D, Dwinnell B, Platt F. Invite, listen, and summarize: a patient-centered
communication technique. Acad Med 2004;80(1):29.
67. O’Leary KJ, Kulkarni N, Landler MP, et al. Hospitalized patients’ understanding of
their plan of care. Mayo Clin Proc 2010;85(1):47–52.
68. Singh S, Fletcher KE, Pandl GJ, et al. It’s the writing on the wall: whiteboards
improve inpatient satisfaction with provider communication. Am J Med Qual
2010;26(2):127–31.
69. Sehgal NL, Green A, Vidyarthi AR, et al. Patient whiteboards as a communication
tool in the hospital setting: a survey of practices and recommendations. J Hosp
Med 2010;5(4):234–9.
70. Arora VM, Schaninger C, D’Arcy M, et al. Improving inpatients’ identification of
their doctors: use of FACEÔ cards. Jt Comm J Qual Patient Saf 2009;35(12):
613–9.
71. Ferranti DE, Makoul G, Forth VE, et al. Assessing patient perceptions of hospital-
ist communication skills using the Communication Assessment Tool (CAT).
J Hosp Med 2010;5(9):522–7.
72. Simons Y, Caprio T, Furiasse N, et al. The impact of facecards on patients’ knowl-
edge, satisfaction, trust, and agreement with hospital physicians: a pilot study.
J Hosp Med 2014;9(3):137–41.
73. Goldzweig CL, Orshansky G, Paige NM, et al. Electronic patient portals: evi-
dence on health outcomes, satisfaction, efficiency, and attitudes: a systematic re-
view. Ann Intern Med 2013;159(10):677–87.
74. Walker J, Darer JD, Elmore JG, et al. The road toward fully transparent medical
records. N Engl J Med 2014;370(1):6–8.
75. Feldman HJ, Walker J, Li J, et al. OpenNotes: hospitalists’ challenge and oppor-
tunity. J Hosp Med 2013;8(7):414–7.
76. Pell JM, Mancuso M, Limon S, et al. Patient access to electronic health records
during hospitalization. JAMA Intern Med 2015;175(5):856–8.
 Patient Experience 151

77. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors’ notes: a
quasi-experimental study and a look ahead. Ann Intern Med 2012;157(7):461–70.
78. Horwitz LI, Detsky AS. Physician communication in the 21st century: to talk or to
text? JAMA 2011;305(11):1128–9.
79. Shultz SK, Wu R, Matelski JJ, et al. Patient preferences for test result notification.
J Gen Intern Med 2015;1–6. http://dx.doi.org/10.1007/s11606-015-3344-0.
80. Murphy R, Barron M, Miller T, et al. Implementation of a “Four C’s” real-time feed-
back tool to assess patient satisfaction and provider communication [abstract].
Journal of Hospital Medicine 2015;10(suppl 2). Available at: http://www.
shmabstracts.com/abstract/implementation-of-a-four-cs-real-time-feedback-tool-
to-assess-patient-satisfaction-and-provider-communication/. Accessed August
21, 2015.
81. Banka G, Edgington S, Kyulo N, et al. Improving patient satisfaction through
physician education, feedback, and incentives. J Hosp Med 2015;10(8):497–502.
82. Rao JK, Anderson LA, Inui TS, et al. Communication interventions make a differ-
ence in conversations between physicians and patients: a systematic review of
the evidence. Med Care 2007;45(4):340–9.
83. Gawande A. Personal best. The New Yorker 2011.
84. Stein J, Payne C, Methvin A, et al. Reorganizing a hospital ward as an account-
able care unit. J Hosp Med 2015;10(1):36–40.
85. Coulter A, Locock L, Ziebland S, et al. Collecting data on patient experience is
not enough: they must be used to improve care. BMJ 2014;348:g2225.
86. Reeves RJ, West E. Patient feedback as a way to improve quality of care. BMJ
2014;348:g2953.
87. Trebble TM, Hansi N, Hydes T, et al. Process mapping the patient journey: an
introduction. BMJ 2010;341(aug13 1):c4078.
88. Michtalik HJ, Yeh H-C, Pronovost PJ, et al. Impact of attending physician work-
load on patient care: a survey of hospitalists. JAMA Intern Med 2013;173(5):
375–7.