Part 1: A New Way of Thinking About Quality Improvement in Healthcare

Part 1: A New Way of Thinking About Quality Improvement in Healthcare

By Susan Butterworth, PhD, MS and Amanda Sharp, MPH

Improving Quality Through Satisfaction: A Four-Part Series

Part 1: A New Way of Thinking About Quality Improvement in Healthcare
Part 2: A Happy Patient: What Drives Patient Satisfaction?
Part 3: A Happy Provider: Strategies to Increase Employee
​Part 4: Communication Approach: Using Best Practice

Quality Improvement (QI) measures are often boiled down to policy and procedural processes – initiatives that focus more on structural organization than on a systematic approach for improved interpersonal interactions and interventions. For an organization that pursues accreditation, either to meet regulatory requirements or distinguish themselves from competitors, there is pressure to adhere to quality measures that demand streamlined referral policies, care coordination, and timely care.1 Obviously, this type of quality control does lead to more successful organization, efficiency, documentation, and transparency of a healthcare business. However, there is a significant gap in the pursuit for quality control that is rarely acknowledged in accreditation programs. Surprisingly, even when an organization uses patient satisfaction surveys to pursue regulation standards, there is little mention of QI in regards to actual patient interaction and communication standards.

Healthcare quality can be divided into three areas: clinical decision-making, patient safety, and patient experience – each with distinct measurement and improvement technologies.2 We will be focusing on QI as seen through the patient experience lens. As you probably already know, the launch of a pay-for-performance model encourages a more whole-systems approach; for example, hospitals will receive financial incentives for higher quality care and penalizations for lower quality care. Since quality is accounted for by both measures of patient outcomes and patient satisfaction, the focus on controlling patient satisfaction has become a top priority. In fact, according to HealthLeaders Media’s 2013 Industry Survey data, more than half of healthcare executives say patient experience and satisfaction is one of their top three priorities.3

In this four-part series we will explore the strategies for connecting each piece of the puzzle: improving patient satisfaction, enhancing employee satisfaction, and engendering a communication approach that is sustainable in the resulting environment. In Part I, let’s consider, in general, how the pursuit of quality care via improved patient satisfaction can encompass improved clinical outcomes and result in a more positive experience for all key stakeholders.

The most common measure of patient satisfaction is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This assessment contains 32 questions which measure nine key topics: communication with doctors; communication with nurses; responsiveness of hospital staff; pain management; communication about medicines; discharge information; cleanliness of the hospital environment; quietness of the hospital environment; and transition of care.4 Not only is there a direct link between HCAHPS scores and profitability, but the literature also supports the interconnectedness of staff engagement on improved HCAHPS scores.5 Four of the nine themes relate directly to staff communication; therefore it is logical to infer that proficient communication has direct influence on quality care and is a foundational element needed to meet the expectations of patient populations and healthcare workers.

An improved patient-centered communication style that has been shown to improve patient satisfaction is one in which the patient not only becomes more informed, but also feels supported. Approaches which demonstrate genuine compassion, empathy, collaboration, and validation are congruent with evidence-based approaches like motivational interviewing and yield improved patient satisfaction.6,7 And effective communication and engagement yield improved patient satisfaction; but the best news is that patient outcomes and patient satisfaction are correlated.8-10

With changes in healthcare systems demanding improved quality care, there is an increasing shift in balance from an outcome-driven standard to one that is experience-driven. Of course, this doesn’t mean that we advocate that you should single-mindedly focus on the patient experience in exclusion of QI strategies that address clinical outcomes; however, this mission to improve clinician communication becomes more compelling as we consider how much more immediate control we have over this component of our QI. There are multiple case studies that demonstrate success in building a meaningful and measurable skillset to motivated clinicians in a relatively short time period.11-13

In summary, as quality measurements become more readily accessible and vetted by patients, they will have more opportunities to choose which facilities and providers are most likely to align with the positive care experience they desire and expect. A key step for pursuing the first of IHI’s triple aims (improved patient experience) and improved outcomes is enhanced communication skills for healthcare workers. Indeed, the benefits of effective physician–patient communication is one of the most durable findings in the medical literature.14 A patient-centered communication standard is an alternative, and perhaps more effective, measurement of quality that begins from the bottom up. By creating a solid foundation based on something as integral as communication styles, those necessary procedural and policy shifts are more likely to be effective and universally utilized. By expanding the scope of quality improvement to include the patient experience, we can take the quest for quality to a deeper and more sustainable level. Initiatives that give structural support to all levels of the care team, and also provide them with tools to demonstrate communication with a sense of compassion, displayed respect for patient choices, and empathy, can jumpstart a concerted plan to improve quality care and patient satisfaction in a way that rewards your efforts many times over.



1 HEDIS & Quality Measurement. Quality Measurement Products. Accessed November 11, 2016.  Available at:

2 Lillrank P. Small and big quality in health care. Internat J Health Care Qual Assur 2015;28(4):356-366.

3 The Rising Importance of Patient Satisfaction in a Value-Based Environment. API Healthcare 2015. Accessed on November 16, 2016. Available at:

4 Hospital Consumer Assessment for Healthcare Providers and Systems. Centers for Medicare & Medicaid Services, Baltimore, MD. Accessed November 16, 2016. Available at:

5 The Rising Importance of Patient Satisfaction in a Value-Based Environment. API Healthcare. 2015. Accessed on November 16, 2016. Available at:

6 Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.; 2012.

7 Butterworth, S., Linden, A. & McClay, W. (2007) Health coaching as an intervention in health management programs. Dis Manage Health Outcomes 2007;15(5):299–307.

8 Lake ET, Germack HD, Viscardi MK. Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals. BMJ Qual Saf 2016;25(7):535-543.

9 Manary MP, Boulding W, Staelin R, Glickman SW. The Patient Experience and Health Outcomes. N Engl J Med 2013;368:201-203.

10 Tsai TC, Orav EJ, Jha AK. Patient Satisfaction and Quality of Surgical Care in US Hospitals. Ann Surg 2015;26(1):2-8. doi: 10.1097/SLA.0000000000000765.

11 Hibbard JH, Greene J, Tusler M. Improving the outcomes of disease management by tailoring care to the patient’s level of activation. Am J Manag Care 2009;15(6):353-60.

12 Linden A, Butterworth SW. A Comprehensive Hosptial-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial. Am J Manag Care 2014;20(10):783-792.

13 Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clinical Pract 2010;16(1):166-174.

14 Aseltine RH, Sabina A, Barclay G, Graham G. Variation in patient-provider communication by patient’s race and ethnicity, provider type, and continuity in and site of care: An analysis of data from the Connecticut Health Care Survey. SAGE Open Medicine 2016;4. doi: 10.1177/2050312115625162. Accessed on November 14, 2016. Available at:

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