Inpatients' willingness to recommend: a multilevel analysis.

BACKGROUND: Satisfaction with health care is one of the most widely assessed measures of hospital care quality, yet studies that account for clustering effects are uncommon. We constructed a multilevel model to identify predictors of willingness to recommend while controlling for clustering effects due to hospital and care unit. We also examined differences in predictors by care unit. PURPOSE: The aim of this study was to identify factors that both influence patient perceptions of care and are potentially modifiable by the hospital delivering care. METHODOLOGY: Our sample includes Hospital Consumer Assessment of Healthcare Providers and Systems survey data collected between July 1, 2007, and June 30, 2008, for 131 hospitals and 33,445 patients. The primary outcome was willingness to recommend the hospital to family and friends. Variables were collected at three levels: patient (Hospital Consumer Assessment of Healthcare Providers and Systems survey item responses and demographics), care unit, and hospital. Data were analyzed using multilevel modeling. We also ran a series of two-level models to explore differences in predictors by care type. FINDINGS: The strongest predictors of willingness to recommend, controlling for clustering effects, were items that generally reflected interpersonal aspects of care such as nursing and physician behaviors. In the two-level models, predictors of willingness to recommend overlapped across care units, but important differences were noted. PRACTICE IMPLICATIONS: Our results suggest that hospitals that wish to improve their performance would benefit most from focusing on interpersonal aspects of care. Hospitals that focus resources on improving in these areas, that assess care units separately, and that investigate the meaning and context of survey responses will be most likely to see improvements in satisfaction scores.

Patient concerns about medical errors in emergency departments.

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.