Background: Inpatient experience quality improvement efforts have traditionally been focused on increasing scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Patients’ open-ended responses about their inpatient experiences may represent a previously unexamined resource for understanding patient motivation behind closed-ended responses. We aimed to describe responses to an HCAHPS open-ended survey question and to compare identified themes to HCAHPS domains.
Methods: We collected all responses to the prompt: “Please comment on good or bad experiences during your inpatient stay” from a single academic center during 2018. After removing clinical content and staff names and excluding comments with fewer than 10 words, we randomly selected 800 comments for qualitative analysis (from a sample of approximately 2,000 comments). Applying directed qualitative content analysis, four team members developed an a priori codebook, checked for coding consistency, discussed emerging themes, and updated the codebook as needed. One team member then independently coded the remaining comments. We calculated frequency of recurring themes for descriptive purposes and compared them to the quantitative HCAHPS survey to determine prevalence of overlapping themes.
Results: Overall, 54% of comments were rated as negative and 46% were positive. HCAHPS domains represented 58% of the most frequently occurring themes including: staff bedside manner, responsiveness to patient requests, discharge process, noise, and cleanliness. Positive comments consistent with HCAHPS domains described nurses, physicians, and staff being professional, caring, and respectful. Negative comments consistent with HCAHPS domains described lack of nurse responsiveness, patients feeling disrespected by clinicians and staff, problems with noise and cleanliness, and frustration with the discharge process. Themes not reflected in existing HCAHPS domains included: emergency department (ED) wait times, amenities (e.g., food, roommates, beds, privacy), and in-hospital complications. The vast majority of comments about amenities were negative. Comments about food were 85% negative. Comments about room amenities (including privacy, comfort of beds, and roommates) were 81% negative. Complication and errors mentioned included bruising from lab draws, lost lab samples, and inpatient medication confusion.
Conclusions: Existing HCAHPS domains captured about half of responses to an open-ended question. However, more than one-third of responses were not related to HCAHPS domains, including ED wait times, complications, and amenities, which were almost all negative. Therefore, in addition to known factors involved in patient care (e.g., ED wait times and medical errors), amenities upgrades may represent an untapped opportunity to improve the overall inpatient care experience.