redo

APA format, in-text citation, references include, 3 pages

Use the scenario in the attachment with 2 articles provided to complete the step for this

Scenario:

Consider the following scenario:

Central Healthcare System (CHS) operates 12 hospitals spread across 10 counties. The administration at CHS monitors patient satisfaction of both short- and long-term hospital patients and their families through surveys. Within the survey, there are multiple-choice questions about their experience and several open-ended questions. Recently, scores have been trending downward, particularly at CHS sites serving patient populations with high percentages of racial and ethnic minorities, and CHS is considering action to address these declines and help improve service delivery.

In this scenario, CHS administrators are in the Information phase of a data-driven decision-making process as they review the analyses of patient-experience scores and develop summaries for stakeholders. The analyses examine the strength of the relationships between various variables and reveal pronounced disparities among patients of varied ethnic backgrounds. CHS leaders are unsure which factors may contribute to the disparities and how they should focus efforts to address them. They begin to consult scholarly literature to better understand the disparate outcomes and guide them as they consider targeted interventions to improve patient experiences and uphold their commitment to equitable healthcare service delivery.

Do:

· Analyze the quantitative and qualitative data results found in the two articles.

· Explain what they mean.

· Describe the data’s strengths and limitations

· Describe how you would use these data for HSO decision-making.

· Summarize the data.

· Explain how your summary could support a decision recommendation. 

Research Article

What Do Patients Want? A Qualitative
Analysis of Patient, Provider,
and Administrative Perceptions
and Expectations About Patients’
Hospital Stays

Sansrita Nepal, MD1,2,* , Angela Keniston, MSPH1,2,*, Kimberly A Indovina, MD1,2,
Maria G Frank, MD1,2, Sarah A Stella, MD1,2, Itziar Quinzanos-Alonso, MD1,2,
Lauren McBeth, BA1,2, Susan L Moore, PhD, M SPH3,4, and Marisha Burden, MD2

Abstract
Patient experience is increasingly recognized as a measure of health care quality and patient-centered care and is currently
measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS survey
may miss key factors important to patients, and in particular, to underserved patient populations. We performed a qualitative
study utilizing semi-structured interviews with 45 hospitalized English- and Spanish-speaking patients and 6 focus groups with
physicians, nurses, and administrators at a large, urban safety-net hospital. Four main themes were important to patients: (1)
the hospital environment including cleanliness and how hospital policies and procedures impact patients’ perceived autonomy,
(2) whole-person care, (3) communication with and between care teams and utilizing words that patients can understand, and
(4) responsiveness and attentiveness to needs. We found that several key themes that were important to patients are not fully
addressed in the HCAHPS survey and there is a disconnect between what patients and care teams believe patients want and
what hospital policies drive in the care environment.

Keywords
patient expectations, patient engagement, patient feedback, patient, satisfaction

Introduction

Patient experience has been described as a cornerstone of

high-value, high-quality health care (1). Institutions with

higher measures of patient experience tend to score higher

overall on measures of quality (2-12). Over a decade ago, the

Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) was developed, and in 2010, it was

deployed across US hospitals. However, because of issues

with response rates, the length of the survey, and the fact that

it might not cover key areas deemed important by patients,

some experts are calling for a revision to the current

HCAHPS framework (13,14).

The HCAHPS has a robust development history including

guided focus groups dating back to the late 1990s and early

2000s (15-17). However, these focus groups primarily

included Medicare patients from relatively educated back-

grounds and with limited diversity. Despite its robust

upbringing, many questions exist about the best way to apply

it and whether or not the various versions of HCAHPS may

have inherent biases (18-23). Additionally, over time, trends

in hospitalization and patient expectations of care may have

evolved.

1 Division of Hospital Medicine, Denver Health, Denver,

CO, USA

2 Division of Hospital Medicine, University of Colorado School of Medicine,

Aurora, CO, USA
3 Community and Behavioral Health, Colorado School of Public Health,

Aurora, CO, USA
4 Division of General Internal Medicine, University of Colorado, Aurora,

CO, USA

* Both the authors are first co-authors.

Corresponding Author:

Sansrita Nepal, Division of Hospital Medicine, Denver Health, 660 Bannock

St, Denver, CO 80204, USA.

Email: sansrita.nepal@dhha.org

Journal of Patient Experience
2020, Vol. 7(6) 1760-1770
ª The Author(s) 2020
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DOI: 10.1177/2374373520942403
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Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further
permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

https://orcid.org/0000-0001-6951-7778

https://orcid.org/0000-0001-6951-7778

mailto:sansrita.nepal@dhha.org

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It has been suggested that hospital care will advance by

learning from patients and their families and involving them

in efforts to monitor and improve care (24). Accordingly, we

aimed to (1) explore concepts identified by hospitalized

patients as being important to them during hospitalization,

(2) explore concepts believed by physicians, nurses, and

administrators to be important to patients during hospitaliza-

tion, and (3) identify gaps and similarities between patient

and health care professional perceptions and expectations.

Methods

Study Design

We conducted 45 semi-structured interviews with hospita-

lized patients and family members or caregivers and 6 focus

groups with hospital-based health care professionals. The

project period, including study design and implementation,

interviews and focus groups, and analysis, was from October

2015 to August 2018. Focus groups with health care profes-

sionals were held from November 2016 to July 2017. Semi-

structured interviews with hospitalized patients and their

families were held from March 2016 to May 2017. Inter-

views with patients and focus groups with health care pro-

fessionals occurred, for the most part, concurrently.

Setting and Participants

The study was conducted at a 525-bed safety-net hospital in

Denver, Colorado. We used stratified purposeful typical case

sampling to identify eligible hospitalized patients. Approx-

imately 15% of Denver Health patients speak a language

other than English, a large majority being Spanish and thus

we sought to ensure that the distribution of patients, by age,

gender, race/ethnicity, language, primary payer, and length

of stay, was representative of the Denver Health patient

population. We included Spanish-speaking patients as pre-

vious work has shown disparities in non-English-speaking

groups with regard to patient experience. While we did not

use patient education as a part of our sampling strategy

because these data are not typically collected as a part of

clinical care, our patient sample reflected the typical patient

hospitalized at Denver Health. Eligible patients were adult

English- or Spanish-speaking patients on an inpatient med-

ical service, identified daily using a screening tool built

within the electronic health record. Eligible health care pro-

fessionals were physicians, nurses, nurse managers, mid-

level administrators, and executives either directly involved

in caring for hospitalized patients or responsible for patient

experience and employed by the hospital. Patients or health

care professionals who refused to participate, patients who

lacked decisional capacity as determined by their primary

care team, patients with hearing or speech impediments that

precluded regular conversation, patients on hospice/com-

fort care, pregnant patients, and prisoners were excluded.

Participants were recruited using in-person invitations for

hospitalized patients and email/phone call invitations for

health care personnel. Stratified purposeful typical case

sampling was used to identify hospitalized patients.

Patients without any exclusion criteria were invited after

the second day of their hospitalization to participate in the

study. Health care professionals were recruited using con-

venience sampling methods.

Patients and family members present were consented and

interviewed in the patient’s private or semi-private hospital

room. Spanish-speaking patients and family members pres-

ent during the interview were consented and interviewed in

Spanish by interviewers fluent in Spanish. Health care pro-

fessionals were consented as a group, and focus groups were

conducted in a private conference room.

Interview Guide

Semi-structured interviews with patients and family mem-

bers present used open-ended questions to explore key attri-

butes of an ideal experience during hospitalization. Focus

groups used open-ended questions to explore what health

care professionals believed patients felt was important dur-

ing hospitalization. Questions were derived from HCAHPS

survey domains and literature reviews. Interview and focus

group guides are presented in Online Supplement 1. The

ultimate purpose of our study was to inductively explore the

perceptions of patients, physicians, nurses, and administra-

tors with the goal of developing a conceptual framework

from the themes and subthemes identified, and thus the

semi-structured interview questionnaire served as a guide

to start the conversation with patients and focus group

participants.

Data Collection

Eligible patients were identified and consented by 1 of the

2 investigators (H.H. and L.M.) and interviewed by 1 of the

6 investigators (S.N., K.I., M.F., S.S., I.Q., and M.B.). Nei-

ther the interviewer nor any observers were wearing a white

physician’s coat during interviews with patients and were

not a member of the patient’s care team. Focus groups were

led by 1 of the 4 investigators (S.N., S.S., M.B., and M.F.).

Physicians, nurses, nurse managers, mid-managers, and

executives were interviewed in separate focus groups to

mitigate any group dynamic issues that could arise from

potential power differentials. Two investigators (H.H. and

L.M.) observed and augmented interview and focus group

transcripts with written notes. Recruitment of participants

was halted when no new codes or themes emerged during

the analysis.

Interviews and focus groups were audio-recorded, de-

identified, professionally translated, and transcribed. Any

identifiers inadvertently captured on the audio files were

removed during professional transcription and not retained

in any way.

Nepal et al 1761

Analysis

Transcribed interviews and focus groups were coded by

3 study team members (A.K., H.H., and L.M.) using

Atlas.ti software (version 7.5.6, Scientific Software

Development GmbH). Disagreements in coding were

discussed until a consensus was reached. A thematic

analysis was conducted using an inductive method at the

semantic level (25). Consensus across 6 team members

(S.N., A.K., K.I., S.S., H.H., and L.M.) was reached

through independent review of the interview and focus

group data along with regular meetings to discuss iden-

tified themes and subthemes. A synthesis of results

emerging from focus group analysis was summarized

and compared to the qualitative results gleaned from the

patient interviews with the goal of identifying congruent

and dissonant themes.

Results

We approached 62 patients and interviewed 45 patients from

March 22, 2016, to May 15, 2017. Forty-nine patients con-

sented, with 4 subsequently excluded following consent.

Thirteen patients declined or were excluded prior to consent.

Table 1 summarizes the characteristics of the patients inter-

viewed. Patient participants described 4 domains during

their hospitalization that were important to them: (1) hospital

environment including cleanliness and impact of hospital

policies on patient autonomy, (2) whole-person care, (3)

communication with and across care teams with words that

patients can understand, and (4) responsiveness and

attentiveness. Figure 1 presents a conceptual framework

derived from the themes and subthemes from the patient and

family interviews. Table 2 provides additional illustrative

quotations for the themes and subthemes informing our con-

ceptual framework.

Patient Themes

The Hospital Environment Influences How Patients
Perceive Their Care

Hospital policies and procedures affect patient perceptions of
autonomy and may contradict patient preferences. Participants

described a lack of control, helplessness, lack of self-

advocacy, and vulnerability during their hospitalization.

Dependency on staff due to their physical limitations, hos-

pital rules, and inconsistent staff response time made the

hospital experience frustrating and intensified feelings of

loss of control and vulnerability. Patients perceived that the

priorities of the hospital (rules, policies, and procedures)

were not in sync with patients’ preferences and that the

hospital did not consider the patient when scheduling clinical

activities such as rounding times, procedures, and blood

draws. Patients suggested that hospitals should better align

clinical workflows and care processes with patient comfort,

rather than hospital staff convenience, as the primary

motivator.

Lack of privacy was identified as a critical concern by

patients and having to share hospital rooms with other sick

patients was viewed as a lack of respect for patients and their

privacy. Patients who reported having a roommate were par-

ticularly concerned about confidentiality, with respect to

sensitive medical and psychiatric information. Disrupted

sleep, noise, nudity of the room partners, and sharing the

restroom with another ill person added additional stress to

the patients.

Importance of cleanliness of the environment. The hospital

environment (comfort, cleanliness, and privacy) was seen

as a surrogate for how patients would be treated while

hospitalized. Patients noted they were relieved when they

saw that staff made efforts to keep the environment clean

and patients as comfortable as possible. Many patients

viewed factors such as a functional television, lights in

accessible locations, consistent cleaning services, family

being allowed to stay overnight, and quality of the food

as important environmental factors that play a role in their

comfort and well-being.

Whole Person Care With the Patient at the Center

Importance of patient-centered care. Participants described a

desire for their hospital care providers to honor their prefer-

ences regarding autonomy and level of their own involve-

ment in their care. Preferences varied regarding shared

decision-making—some of the patients wanted to know less,

Table 1. Patient Demographics.

Demographic value
English-speaking Spanish-speaking

N ¼ 22 N ¼ 23

Age
18-29 3 (14) 0 (0)
30-39 1 (4) 5 (22)
40-49 2 (9) 5 (22)
50-59 8 (36) 4 (17)
60-69 5 (23) 4 (17)
70-79 3 (14) 3 (13)
80-89 0 (0) 2 (9)

Gender
Female 14 (64) 11 (48)
Male 8 (36) 12 (52)

Race/ethnicity
Black 4 (18) 0 (0)
Hispanic 11 (50) 23 (100)
White 7 (32) 0 (0)

Payer
Medically indigent 1 (4.5) 14 (61)
Medicaid 11 (50) 1 (4.5)
Medicare 9 (41) 7 (30)
Commercial/Denver Health
Medical Plan

1 (4.5) 1 (4.5)

1762 Journal of Patient Experience 7(6)

while others wanted to know more. Some patients reported

feeling comfortable deferring clinical decisions to clinical

staff but wanted to understand the plan of care, thereby

balancing the power dynamics between patients and their

care team.

Seeing the patient as human, taking measures to avoid
dehumanization, and treating patients with empathy. Patients

described a strong desire for a human connection with their

nurses, doctors, and other hospital staff. Patients saw even

small gestures of kindness, such as calling their employer on

their behalf to request sick days or finding a family mem-

ber’s phone number, as going above and beyond the usual

standard of care. Patients desired hospital staff to be resilient

and pleasant, to appear to enjoy their jobs, to answer

patients’ and families’ questions, to listen to patients, and

to explain things in a way that patients and their families can

understand. Patients perceived that what differentiates aver-

age care from exceptional care is looking beyond the tubes

and machines to recognize that there is a human being

behind them and treating patients like more than just a

number.

Clear Communication Between the Patient and Care
Team

Care teams need to communicate with each other. Receiving

contradictory messages from different clinicians providing

care was frustrating for patients. Patients perceived that the

delays in procedures and changes in care plans reflected

disorganization and conflict among the health care provi-

ders. Participants described wanting clear, consistent, and

coordinated communication.

Communicating with words patients understand. Participants

expressed wanting clinical staff to clearly explain their

disease and treatment plan in a way that they understand.

While patients did not mind clinical staff using medical

terminology at the bedside, they expected that clinical

staff would take the time to communicate with them in

layman’s terms. While most participants expressed that

they lacked a clear understanding of their disease due

to an underlying lack of medical knowledge, they per-

ceived that clinical staff could bridge this gap by taking

time to explain information well.

Figure 1. Conceptual framework for patient interview themes and subthemes.

Nepal et al 1763

Table 2. Patient and Family Themes and Subthemes With Exemplar Quotations.

Theme and subthemes Quotations

Hospital environments influence how patients perceive their care

Importance of cleanliness of environment “Nobody came to clean my room the whole weekend that I was there. For
my whole stay. I thought that was awful because you know—without a
clean room you’re bound to get infection. So I told my best friend and I
guess he took care of it for me. I didn’t want to get nobody in trouble.”
(patient 49)

Hospital rules, policies, and procedures affect patient
perceptions of autonomy and contradict patient preferences

“The doctors are discussing your personal business and here, this person
over here listening [referring to roommate]. Like oh, you know. That’s
not good. Isn’t that a compromise issue of doctor and patient
information? What if she knows somebody that doesn’t like me? You can
put a whole bunch of stuff on Facebook.” (patient 23)

“The laboratory keeps coming in poking me when I’m telling them that I
don’t have any more veins, and I’m all bruised up and they like just
come and poke me and they expect that like you know I’m fine with it.”
(patient 42)

“But there are some things that bother me. I don’t like them, but perhaps
it’s for my own good, so it won’t hurt me or it has to be due to my
health, for my own good. They come here, they wake me up all the time,
or I ask for a meal they can’t send me and they send over whatever they
want.” (patient 34)

Whole person care that is patient-centered

Importance of patient-centered care “They actually come in and talk to you; you know the palliative care and the
social workers and things like that. You actually see them before the
medical team gets here in the morning. They send one of the people out
and he gives you like an overview of what you’re going to be talking
about. And then a little while later the whole team comes in so you’re
not caught off guard about anything.” (patient 35)

“The noise, the lighting and none of that bothers me. When I go to sleep I
sleep but, for example, last night I was very sick and they didn’t let my
wife stay over because we’re two men sharing the room. Well, I needed
to have my wife there beside me, you understand?” (patient 45)

Seeing the patient as human, taking measures to avoid
dehumanization

“They treat you like you’re a person. Like you’re worthy.” (patient 14)
“The team here, I feel like they really care. And I feel like someone you

know, not just a number to them.” (16)
Treating patients with empathy “Then when I was in the bathroom I called for some help getting out, and I

didn’t really get the help I was looking for. I could tell she just didn’t want
to do it. It is hit and miss. It all depends on who’s working that day and
what their work ethic and personality is.” (patient 43)

“I haven’t been mistreated, not a bad looking face, nothing, nothing. On the
contrary, we’re going to help you, we support you, you’re going to make
it, this disease is no longer a negative one, it’s just like any other illness,
you can live 32, 33 more years, like nothing is happening, you can have
kids, you can have a family and I’m like . . . I mean, they took the negative
stuff I had away from the disease.” (patient 26)

Clear communication with patient and care team

Communicating in a way that patients can understand “First they talk among them, I don’t know the situation they’re seeing,
everything, they come in, they talk to me, they listen to me lungs, they
check up on me, whatever they must do, and sometimes among them
they also talk a bit more, well, this is what will do, basically they consider
this in group when the patient is there with them so that the patient will
also know what’s happening, not just they come in and they say you’re
going to use this blue drainer [references a medical device] and that’s it,
go. They tell you, look, they’re going to give you this [references a
medical device] for this and this and this reason. And we see this is the
best thing for you but we also want to know how you feel about it. So
they take you into account.” (patient 27)

(continued)

1764 Journal of Patient Experience 7(6)

Responsiveness and Attentiveness

Attention to patient’s physical and emotional needs. Patients

noted that they expect respect, kindness, and attentiveness

from their care team. Some described experiencing delays

and inconsistencies in responsiveness to the call light and to

their basic needs. Furthermore, having clear and accurate

expectations regarding waiting times and other delays is

important so patients are not left wondering about the status

of their request or their clinical care. Participants noted that

when immediate or anticipatory care did occur, it positively

affected their experience. Participants further described a

sense of emotional safety when staff had a confident demea-

nor and positive attitude and paused to take time to interact

with patients as human beings.

Worthiness of Care

Past choices leading to self-blame and passivity in care. Due to

their choices in the past, some participants blamed them-

selves for their disease and therefore tolerated suboptimal

treatment in the hospital. They did not see themselves as

worthy of better treatment and they were embarrassed to

demand more from their care providers. Many participants

did not speak up due to embarrassment, helplessness, lack of

self-advocacy, a feeling of not wanting to get anyone in

trouble, worrying that their care would be affected nega-

tively, or not wanting to be a burden to the staff.

Focus Groups

Six focus groups were conducted with a total of 45 partici-

pants. The focus groups included 13 attending physicians, 10

nursing staff, 15 managers, and 7 executives. Administra-

tors, physicians, and nurses were interviewed separately.

Several themes noted by patients such as lack of control,

communication between care providers, empathy, staff

engagement, expectation setting, and prioritization of health

system goals over individual patients were also noted in the

focus groups of physicians, nurses, and administrators.

Online Supplement 2 provides illustrative quotations for the

themes and subthemes identified. Figure 2 provides a dia-

gram for the themes and subthemes from the focus groups

highlighting commonalities between types of health care

professionals and unique themes identified.

Table 2. (continued)

Theme and subthemes Quotations

Care teams need to communicate with each other “I feel like it’s all communicated. I let them do the medical decisions, they’re
smart. But they go over everything and the whole team comes. With the
pharmacy, also three doctors come in here in the morning and they ask
me. And we’re all on the same page with it. It’s so clear and I have an
understanding of everything. It’s just real nice.” (patient 16)

Responsiveness and attentiveness

Attention to patient’s physical and emotional needs “The same way if it’s not ringing or not answering and you feel like you want
to pee and you press it, nobody answers. You just have to keep on
pressing it until somebody answers and I want to pee. I’ve peed myself
already. I have to keep on pressing until somebody answers.” (patient 36)

“Well, very good. See, last night one of them gave me a bath and please I’d
like to take a bath but they don’t have a small chair so I can take a bath,
oh, I’ll help you with your bath right now. And she went, she prepared
the bath, she helped me take a bath and get dressed, what else can I ask?”
(Patient 33)

“I went to go get a CAT scan. The transportation lady, you know she—they
put you in the wheelchair and they take you down there. I didn’t like how
she pretty much just stuck me in the hallway when there’s a waiting area
right there . . . ? Yeah, there was men doing a lot of construction, and I
had a really bad headache and I couldn’t—I was connected to all these, I
call the leash. I couldn’t get up and move myself. I would like you know if
there’s a waiting area right there, you know just to put patients that are
waiting in a—that’s why it’s called the waiting room.” (patient 38)

Worthiness of care

Past choices leading to blame and passivity in care “Once he comes in the morning [referring to provider], I don’t like to
bother him again. I know he’s got a lot of other patients worse off than
me. I feel like I ain’t worth it sometimes . . . probably because of the life I
led, the drugs I’ve done and the way I’ve acted and—up to no good and
stuff I guess.” (patient 3)

Nepal et al 1765

While the themes from patient interviews and focus

groups were similar, the physician focus group noted that

despite feeling like they know what patients and families

genuinely want and need while hospitalized, depersonaliza-

tion occurs due to the stress of busy day-to-day work sche-

dules and burnout from an unsustainable workload. The

concept of having to direct or coordinate care was a unique

finding from the nurse focus group, while health care admin-

istrators described the need for human touch and empathy

from clinical staff when hospitalized.

Discussion

The most important findings of this study are (1) patients

identified factors that are not currently captured in the

HCAHPS surveys, such as how hospital policies and proce-

dures impact their perceived autonomy, that whole-person

care is important, and the need for cohesive communication

between care team members; (2) while physicians, nurses,

and administrators can articulate what patients find most

important, patients’ experiences and staff focus groups indi-

cate that hospitals struggle to bridge the gap between

understanding patient needs and actually meeting those

needs; (3) physicians noted that despite feeling like they

know what patients and families genuinely want and need

while hospitalized, depersonalization occurs due to the stress

of busy day-to-day work schedules and burnout from an

unsustainable workload; and (4) there is a subgroup of

patients who expressed feeling a lack of worthiness and a

reluctance to self-advocate.

The HCAHPS development began as early as the 1990s

through a variety of focus groups, but these focus groups had

several limitations, as they asked patients to recall hospita-

lizations as long as 1 year prior and utilized questions tai-

lored to address a battery of *66 items (15-17). Recent

articles have cited the concerns that HCAHPS may not ade-

quately cover key areas important to patients and has several

logistical issues including length of the survey and high

literacy level (13).

We found several domains not covered in the current

HCAHPS survey that are likely important to high-quality

care. These include hospital policies adversely impacting

patient autonomy (26), communication between care teams

(27), and whole-person care (28). With regard to policies, a

Figure 2. Diagram of focus groups’ themes and subthemes.

1766 Journal of Patient Experience 7(6)

variety of policies and procedures were referenced by

patients, including the timing of procedures and when a

patient is or is not allowed to eat/drink, visitation policies,

and room sharing policies. Many of the references of policies

by patients centered on patients reporting they felt as though

they lacked autonomy and control. The lack of privacy due

to having to share rooms is not new knowledge, with other

studies reporting this same finding; however, to our knowl-

edge, the HCAHPS survey does not include questions asking

about privacy or whether the patient was in a shared room or

not. While the HCAHPS survey includes questions exploring

how nurses and physicians communicated with the patient,

the HCAHPS survey instrument does not include questions

about how the patient perceives the care team members

communicated with each other. Our study corroborates the

need to continue to ask patients about how they perceived

nurses and physicians communicated with them and suggests

there is also a need to ask patients how they perceived care

team members communicated with each other about their

care. Some of these domains could be incorporated into

future surveys (ie, how well did your care team communicate

with each other and how did hospital policies affect your

hospital stay). Some of the confusion around hospital poli-

cies could likely be mitigated with improved patient-

centered communication around patient preferences and an

understanding of safety protocols.

In our safety-net population, we also found that certain

patients may not feel worthy of advocating for themselves in

particular when feeling that their illness may be due to pre-

vious poor choices. While this finding was noted in a smaller

group of patients (N ¼3), this phenomenon may be more

prevalent in hospital settings that serve underserved popula-

tions and thus may be a future area to potentially focus on.

Additionally, we may have captured unique perspectives by

interviewing patients in person during their hospitalization,

as the lack of a reliable phone number or address may pre-

clude some of our most vulnerable patients from responding

to the HCAHPS survey. Our finding on whole-person care is

similar to a recent study that reported that person-focused

interventions could improve the patient experience (28).

Recently published articles support the finding that hospital

policies affect patient experience, and those policies need to

be patient-centric and flexible (26). Similarly, another study

found that patients in private rooms are more likely to report

a top-box score for overall hospital rating, hospital recom-

mendation, call button help, and quietness in HCAHPS (29).

We found that many of the themes noted by patients (lack

of control, communication between care providers, empathy,

staff engagement, expectation setting, and health system

priorities) were also noted by health care professionals. In

addition, we noted there were some unique themes identified

during focus groups with physicians, nurses, and adminis-

trators. In particular, administrators described the need for

human touch and empathy from health care staff when hos-

pitalized. The concept of having to direct or coordinate care

was a unique finding from the nurse focus group, while the

concept of depersonalization and burnout was a unique find-

ing from the physician focus groups. The health care profes-

sionals who agreed to participate in our focus groups came

from a cross-section of units and departments. Depersonali-

zation and burnout reported by the physicians who partici-

pated in our study are findings that have been described in

the literature by other researchers and may serve as an expla-

nation for why physicians feel unable to completely meet the

needs of patients. Interestingly, focus group results illu-

strated that health care professionals’ own experience as a

patient (or a patient’s family member) imparts an under-

standing that they are able to apply to their own work caring

for patients. This concept is mirrored in perspective pieces

published by clinicians (30). Our findings suggest that while

health care professionals appear to have a genuine under-

standing of what patients want and need during their hospi-

talization, this awareness does not always translate into

reliable fulfillment of these needs and wants as experienced

by hospitalized patients.

Although the ideas expressed by health care professionals

were mostly congruent with those expressed by patients, the

experiences relayed by patients point to a gap in translating

these ideas into clinical practice. Future work should be

directed at understanding the reasons for this gap between

health care professionals’ knowledge and everyday

practice.

For instance, it is plausible that clinical workload, cognitive

load, competing demands, burnout, or systems factors may

explain why these behaviors are not always modeled in daily

practice.

Our findings also highlight the role of system-level bar-

riers in hindering the patient-centeredness of policies and

procedures that patients, families, caregivers, clinical staff,

and administrators all deem important. Modifying policies

and procedures governing activities such as clinical round-

ing, scheduling of procedures, and timing of blood draws

would require a system-level change in hospital operations,

which is challenging to execute. While certain policies pro-

tect our patients and families, others are likely detrimental to

patients who are trying to heal, such as those that interrupt

patient sleep or disallow patients from having family mem-

bers or caregivers stay with them overnight. The need for

standardized yet flexible processes has been recognized as a

key strategic framework in patient-centered care (31). To

stay competitive, health care organizations need to develop

effective and efficient processes that are patient-centered,

informed by the newest models of operation management

and research, and designed for our patients and families.

Our study had several limitations. This study aimed to

describe the experiences of patients, caregivers, and health

care professionals at a safety-net hospital, and thus the

results may not be applicable in other settings. In addition,

there was a potential for participation bias if patients who

declined to participate were different in some way from

those who agreed to participate. Due to using a convenience

sample for the focus groups, there is also a potential for

selection bias among the health care professionals included

Nepal et al 1767

in the study. Also, patients who did not speak English or

Spanish were excluded from this study, and these patients

may have had different experiences. We recognize that

patient experience may vary according to language, race/

ethnicity, or other cultural factors; however, this analysis

was intended to propose a high-level framework. Future

work should be conducted to explore these potential differ-

ences. Conducting the patient interviews while the patients

were still hospitalized may have inhibited patients’ willing-

ness to fully disclose their perceptions regarding their expe-

rience. They also would not have experienced the discharge

process during that respective hospitalization and thus the

needs around the discharge and transition process are not

addressed in this study. Finally, interviews and focus groups

were conducted by physicians, which could have influenced

participant disclosures. However, to mitigate this potential

issue, neither interviewers nor observers wore a white phy-

sician’s coat during interviews with patients or focus groups.

Our study also has several strengths. Because we inter-

viewed patients during their hospital stay, their experience of

hospital care was likely very real and fresh on their minds.

We included both English- and Spanish-speaking patients,

and the interviews were conducted by native English and

Spanish speakers. This work incorporates a more diverse and

underserved population than the original focus groups

described by Sofaer et al., which included a predominantly

white population (62.8%) and 57% of the participants had at

least some college or 2-year degree or vocational school or

higher education. Educational levels for the population who

responded to HCAHPS at our institution was high school.

We also sought the perspectives of the clinician and admin-

istrative team, which we believe are also important to under-

stand. Few studies have paired patient, care team, and

administrative perspectives.

Conclusions

We found several critical themes among hospitalized

patients that are not currently captured in standard patient

experience assessments. We found that there is a disconnect

between what patients and clinical staff believe patients need

and want and what hospital policies and environments drive

in the care environment. Certain vulnerable populations may

be less inclined to self-advocate regarding their needs, and

additional measures may need to be taken to ensure the needs

are met.

Authors’ Note

The study was reviewed and approved by the Colorado Multiple

Institutional Review Board (COMIRB), University of Colorado,

Denver. Written consent was obtained from all participants prior

to conducting any interviews or focus groups and all participants

received a copy of the consent form. Sansrita Nepal and Angela

Keniston are co-first authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support

for the research, authorship, and/or publication of this article: This

study was funded for $25,000 through Department of Medicine

Small Grant and $25,000 through Denver Health Foundation.

ORCID iD

Sansrita Nepal, MD https://orcid.org/0000-0001-6951-7778

Supplemental Material

Supplemental material for this article is available online.

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Author Biographies

Sansrita Nepal, MD, MBA, works as a hospitalist at Denver

Health and is an assistant professor of Medicine at the Univer-

sity of Colorado. Her research interests include patient experi-

ence and resident education. She has an MBA in healthcare

administration.

Angela Keniston, MSPH, is the director of Data and Analytics for

the Division of Hospital Medicine at the University

of Colorado.

She has expertise in research design, mixed methods approaches,

qualitative and quantitative methods, data collection, management

and analysis, user-centered design, and stakeholder engagement

planning and execution. She has worked for the last 15 years

exploring how care for hospitalized patients, and how patients and

families experience care during a hospitalization, might be

improved, in particular for vulnerable, socio-economically disad-

vantaged patients.

Kimberly A Indovina, MD, is an assistant professor of Medicine at

the University of Colorado and practices hospital medicine and

palliative medicine at Denver Health.

Maria G Frank, MD, is a hospitalist and medical director of the

Biocontainment Unit at Denver Health Hospital Authority. She is

an associate professor of Medicine at the University of Colorado,

School of Medicine.

Sarah A Stella, MD, is an internal medicine hospitalist at Denver

Health and an associate professor of Medicine at the University of

Colorado. She is passionate about improving health outcomes

among patients with complex medical and social needs through

community partnered research, healthcare systems improvement

work, and advocacy.

Itziar Quinzanos-Alonso, MD, is an instructor of Medicine at the

University of Colorado School of Medicine, Division of Rheuma-

tology. Working in the Rheumatology department at Denver Heath.

A native of Mexico, her area of research expertise in underserved

communities. Specifically, working with her colleagues at Denver

Health she has focused on health literacy.

Lauren McBeth, BA, is a project coordinator and data analyst on

the Data and Analytics team for the Division of Hospital Medicine

at the University of Colorado Denver. She received her Bachelor of

Arts in Psychology with an emphasis in Neuroscience from Con-

cordia College in Moorhead, MN and has spent the last five years

compiling and analyzing both quantitative and qualitative data for

the purposes of improving patient care in the hospital inpatient

setting.

Nepal et al 1769

https://www.aha.org/guidesreports/2019-07-24-modernizing-hcahps-survey

https://www.aha.org/guidesreports/2019-07-24-modernizing-hcahps-survey

Susan L Moore, PhD, MSPH, is an associate director at mHealth

Impact Lab. She is the core lead at the Adult and Child Con-

sortiuan for Health Outcomes Research (ACCORDS). She

works at the Colorado School of Public Health and University

of Colorado.

Marisha Burden, MD, is an academic hospitalist and division

head of Hospital Medicine and, an associate professor of Med-

icine at the University of Colorado School of Medicine. She

completed her undergraduate training at the University of Okla-

homa and earned her medical degree from the University of

Oklahoma School of Medicine graduating with the honor of

Alpha Omega Alpha. She completed her residency at the Uni-

versity of Colorado in the hospitalist training track. Her interests

include hospital systems improvement, which includes patient

experience, patient flow, quality, and transitions of care. She

is also very interested in promoting gender equity and is a

member of the Department of Medicine Program to Advance

Gender Equity and the AAMC Group on Women in Medicine

and Science (GWIMS) Equity in Recruitment Task Force. She is

an active member of the Society of Hospital Medicine (SHM)

and a senior fellow of Hospital Medicine.

1770 Journal of Patient Experience 7(6)

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Differences in Patient Experience Between Hispanic
and Non-Hispanic White Patients Across U.S. Hospitals

Jose F. Figueroa · Kimberly E. Reimold · Jie Zheng · Endel John Orav

ABSTRACT
Introduction: Despite the increased emphasis on patient experience, little is known about whether there are meaningful

differences in hospital satisfaction between Hispanic and non-Hispanic whites.

Methods: To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey data (2009–2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients.

Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction.

Results: Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have

graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p, .001) and to rate

it 9 or 10 (72.5% vs. 65.9%, p, .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared

with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher

percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals.

Conclusion: There were significant but only modest-sized differences in patient experience between Hispanic and white patients
across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.

Keywords: disparities/equity of care, patient satisfaction, health policy

Introduction
Patient experience is an essential component of
measuring health system performance.1 Previous
work has shown that high performance on measures
of patient experience is associated with high perfor-
mance with other measures of quality of care,
including clinical processes and health outcomes.2-5

When patients report poor experiences, evidence
shows that they are more likely to delay seeking
necessary medical care and are also at higher risk of
not adhering to treatment recommendations.6-9

Therefore, in recent years, the federal government

has significantly increased emphasis on patient
experience by tying Medicare payments directly to
measures of patient satisfaction through pay-for-
performance efforts, such as the Hospital Value-
Based Purchasing (VBP) Program.10

One area of particular concern is disparities in
patient experience amongHispanic patients. Among
minority populations, Hispanics are the least likely
group to seek medical care when it is necessary,11

more likely to lack health insurance coverage12 and
a usual source of care,13 and often have limited
English proficiency.14 In addition, Hispanics are less
likely to receive important treatments for common
medical conditions compared with non-Hispanic
whites.15-17 As such, barriers in receiving care may
influence how Hispanics perceive the delivery of
care. Therefore, it is critical to understand the extent
to which Hispanic patients may have differences in
experience with hospital care as compared to non-
Hispanics.

Site of care may play an important role in health
care disparities. Previous work found that care for
Hispanic patients is highly concentrated, with more
than half of the Hispanic patients in a small pro-
portion of U.S. hospitals.17 These “Hispanic-serving”
hospitals provided worse quality of care than other
hospitals.17 However, we know little about the extent

Journal for Healthcare Quality, Vol. 40, No. 5, pp. 292–300

© 2017 National Association for Healthcare Quality

The authors declare no conflicts of interest.

For more information on this article, contact Jose F. Figueroa at jfigueroa@

hsph.harvard.edu

This work was supported by the National Institute on Minority Health and

Disparities (Grant No. 1R01MD006230-01A1) at the National Institutes of

Health (NIH). The NIH had no role in the design and conduct of the study;

collection, management, analysis, and interpretation of the data; or

preparation, review, and approval of the article.

The study was approved by the Harvard T.H. Chan School of Public Health

Institutional Review Board’s Committee on the Use of Human Subjects.

Supplemental digital content is available for this article. Direct URL citations

appear in the printed text and in the HTML and PDF versions of the article at

www.jhqonline.com.

DOI: 10.1097/JHQ.0000000000000113

292 September/October 2018·Volume 40·Number 5 www.jhqonline.com

Original Article

Copyright 2018 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

of the influence that these hospitals have on overall
patient experience for Hispanic patients.

Therefore, in this study, we sought to answer three
questions. First, do Hispanics have worse patient
experience in U.S. hospitals compared with non-
Hispanic whites? Second, given that previous evi-
dence has shown that education may affect patient
outcomes and experience, if gaps in patient experi-
ence do exist, to what extent do they vary according
to patients’ level of education?18,19 Finally, are
observed differences in experience between His-
panic and non-Hispanic whites predominantly seen
within the same hospitals, or are they driven
primarily by site of care?

Methods

Data
Hospitals are required to report data onmeasures of
inpatient experience through the Healthcare Pro-
viders and Systems (HCAHPS) survey to the Centers
for Medicare and Medicaid Services (CMS). This
survey was developed by the Agency for Healthcare
Research and Quality. It is administered by hospitals
to a random sample of adult patients up to 6 weeks
after a hospital discharge. We obtained patient-level
data from the 2009 and 2010 HCAHPS surveys from
the Iowa Quality Improvement Organization
(QIO), an affiliate of the Centers for Medicare
and Medicaid Services (CMS). These patient-level
data are different from data available through
Hospital Compare, which contains hospital aggre-
gate data only and, therefore, does not allow for
comparison of Hispanic vs. non-Hispanic responses
within a given hospital.

The HCAHPS survey consists of 27 questions
related to patient experience on the following 10
measures: 2 global measures of patient experience, 6
composite measures of clinical domains, and 2
individual items about the hospital environment.
The 2 global measures are: overall rating of the
hospital on a scale of 0 to 10 and whether or not the
patient would recommend the hospital to family
members or friends. The six composite measures are
related to communication with physicians, commu-
nication with nurses, communication about medica-
tions, pain control, discharge process, and staff
responsiveness. The methodology used by CMS to
calculate composite scores has been described pre-
viously.20 The remaining two items are individual
questions about cleanliness and quietness of the
hospital environment.

The survey also contains self-reported patient
characteristics on the patient’s age, sex, race, health
status, primary language spoken at home, reason for
admission, and level of education. In this study, we
included only patients who identified themselves as
Hispanic white or non-Hispanic white. We excluded
black patients because they have been previously
studied.21

Because of CMS regulations, we were only able to
obtain data on three hospital characteristics: pro-
portion of inpatient admissions who were Hispanics
versus white Medicare patients, hospital size (small
[fewer than 100 beds]; medium [100–399 beds]; or
large [400 or more beds]—the size ranges used by
the American Hospital Association), and major
teaching hospital status (defined as being a member
of the Council of Teaching Hospitals of the
Association of American Medical Colleges). Mas-
sPRO conducted linkage of the AHA survey data to
HCAHPS data.

To define “Hispanic-serving” hospitals, we first
ranked all hospitals by the proportion of their
admitted patients who are of Hispanic ethnicity. We
then defined the top 10% of hospitals with the
highest proportion of Hispanic patients admitted as
the “Hispanic-serving hospitals.” The remaining 90%
of hospitals were defined as non-Hispanic–serving
hospitals.

Outcomes
Our primary outcomes of interest were the two global
measures of patient experience: overall hospital rating
and willingness to recommend the hospital. Secondary
outcomemeasures included the six composites and two
hospital environment measures. Our outcome varia-
bles were constructed using the CMS method, which
represents the percentage of patients who reported the
most positive, or “top box,” response.20 The primary
outcomes were dichotomized as follows: a rating of 9 or
10 versus a rating of 8 or below for hospital rating; and
a rating of “definitely yes” versus “definitely no,”
“probably no,” and “probably yes” for willingness to
recommend. The secondary domains were dichoto-
mized as follows: “yes” versus “no” for dischargeprocess;
“always” versus “never,” “sometimes,” and “usually” for
the remaining measures.

Analysis
Using chi-square tests, we compared the character-
istics of Hispanic and non-Hispanic white patients
and Hispanic-serving hospitals versus non-Hispanic–
serving hospitals. We also used chi-square tests to

Journal for Healthcare Quality September/October 2018·Volume 40·Number 5 293

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compare unadjusted differences in patient experi-
ence for the primary and secondary outcomes across
the two groups.

We then constructed multivariable logistic regres-
sion models where we used generalized estimating
equations (GEEs) to account for the clustering of
patients within hospitals. To capture overall differences
between Hispanic and non-Hispanic white patients, we
used an initial independent correlation structure,
although the final model standard errors were adjusted
for the empirically measured correlation from the
within-hospital residuals. These models were adjusted
for baseline differences in self-reported patient char-
acteristics. To examine whether the differences be-
tweenHispanic and non-Hispanic white patients varied
by their level of education, we dichotomized the
education variable at high school or less and added
the interaction term between dichotomized education
and race, along with all the other covariates above. For
satisfaction measures where the interaction terms were
significant, we stratified our analyses by education level
and compared satisfaction between Hispanic and non-
Hispanic white patients within each level of education.

To identify how much of the overall ethnic
differences were due to differences in satisfaction
within hospitals, we constructed a multilevel logistic
regression model using hospital random effects and
all of the covariates above. The difference between
the overall ethnic gap and the within-hospital gap was
calculated and used to represent the effect of
differences due to the quality of hospitals at which
Hispanics and non-Hispanics were most likely to get
their care. To address the quality gap between
Hispanic-serving hospitals and non-Hispanic-serving
hospitals more directly, we also expanded the GEE
model to include an indicator variable for Hispanic-
serving hospitals and the interaction between
Hispanic-serving hospitals and Hispanic patients.
From these models, we were able to estimate for
each race the difference in satisfaction if they were
seen at a Hispanic-serving hospital versus if they were
seen at a non-Hispanic-serving hospital.

The study was approved by Harvard University’s
Institutional Review Board Committee on the Use of
Human Subjects. Analyses were performed using
SAS, version 9.4.

Results

Patient and Hospital Characteristics
We had data on 3,864,938 respondents who com-
pleted the HCAHPS survey in 2009 and 2010, of

which 238,310 were Hispanic respondents (6.2%)
and 3,626,628 were non-Hispanic white respondents
(93.8%). Compared with non-Hispanic white
patients, Hispanics were more likely to be younger
than 65 years (49.2% for whites vs. 66.5% for
Hispanics, p , .001) and women (60.7% vs. 67.6%,
p, .001) and less likely to have graduated from high
school (12.2% vs. 32.3%, p , .001), report excellent
health (12.9% vs. 21.0%, p , .001), and be admitted
for maternity care (10.7% vs. 24.2%) (Table 1).

We designated 379 hospitals of the 3,796 hospitals
that reported HCAHPSmeasures as Hispanic-serving
hospitals. These hospitals were more likely than non-
Hispanic-serving hospitals to be large (27.9% vs.
23.4%; p , .001) and to be non-teaching hospitals
(87.7% vs. 85.3%; p, .01) (see Table 1, Supplemen-
tal Digital Content 1, http://links.lww.com/JHQ/
A52). Among Hispanic-serving hospitals, the pro-
portion of Hispanic patients admitted was 35.9%
compared with 3.6% in the remaining hospitals.

Patient Satisfaction by Race
We examined the unadjusted relationship between
patient experience and ethnicity. In unadjusted
models, we found that Hispanic patients were more
likely to rate hospitals a 9 or 10 (72.9% vs. 65.9%,
p , .001) and to recommend hospitals (74.2% vs.
70.9%, p, .001) compared with non-Hispanic whites
(Table 2). Hispanics were also more likely to report
more positive experiences on seven of the eight
secondary measures than non-Hispanic whites.

When we adjusted for patient characteristics,
Hispanics were stillmore likely to recommendhospitals
(74.1%) and rate hospitals a 9 or 10 (72.5%) compared
with non-Hispanic whites (70.9% and 65.9%, respec-
tively; both p , .001); they were also still significantly
more likely to report higher scores on communication
with physicians (79.9% vs. 78.3%; p, .001) and about
medications (60.1% vs. 57.7%; p , .001) and also
report more satisfaction related to staff responsiveness
(61.0% vs. 60.4%; p 5 .03) and pain management
(54.1% vs. 50.6%; p , .001) (Table 2). However,
Hispanics showed a slightly lower level of satisfaction
with discharge information (78.5% vs. 79.1%; p5 .003)
and hospital cleanliness (68.6% vs. 69.5%; p5 .004).

Effect of Education
For all of our outcome measures, we found signifi-
cant interactions between the racial differences in
satisfaction and level of education. In adjusted
models stratified by the level of education, both
Hispanic and non-Hispanic patients with at least

294 September/October 2018·Volume 40·Number 5 www.jhqonline.com

Original Article

Copyright 2018 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

some college education were less likely to recom-
mend hospitals or give them a rating of 9 or 10 (see
Table 2, Supplemental Digital Content 2, http://
links.lww.com/JHQ/A53). Among patients with
a high school education or less, Hispanics
gave significantly more positive evaluations on

all 10 HCAHPS measures than non-Hispanic
whites.

Patient Satisfaction by Site of Care
In our within-hospital analyses, which controlled for
the influence of individual hospitals on the patient
experience measures, Hispanics reported more
positive experiences for all 10 HCAHPS measures
(Figure 1). In addition, the gap between Hispanics’
and whites’ experiences was wider in our within-
hospital analyses than in the unadjusted models
except for cleanliness of the hospital environment,
which now showed Hispanics giving a slightly more
positive evaluation (Table 3).

We subtracted the within-hospital differences
from the overall differences to obtain the between-
hospital components of difference. These estimated
components reflect the differences in hospital scores
attributable to the influence of hospitals on patient
experience—which, in turn, reflects the differences
in the average patient experience between Hispanic-
serving hospitals and non-Hispanic–serving hospi-
tals. The between-hospital components of difference
between Hispanics and whites were22.3% points for
recommendation of hospitals and 22.6% points for
ratings of hospitals (Table 3). For all eight secondary
domains, the components were also negative (rang-
ing from 21.4% to 23.3% points). The negative
signs suggest that Hispanic patients get care at
hospitals where, on average, the experience of care
is worse for all patients.

We then compared patient experience of His-
panic and non-Hispanic whites stratified by Hispanic-
serving and non-Hispanic-serving hospitals. Both
whites andHispanics ratedHispanic-serving hospitals
lower than non-Hispanic-serving hospitals on all 10
HCAHPS measures. Hispanic patients in Hispanic-
serving hospitals rated their satisfaction 2.5%–5.8%
lower (depending on the satisfaction measure) than
Hispanic patients in non-Hispanic-serving hospitals.
Likewise, white patients in Hispanic-serving hospitals
rated their satisfaction 4.5%–9.2% lower than white
patients in non-Hispanic-serving hospitals (see
Table 3, Supplemental Digital Content 3, http://
links.lww.com/JHQ/A54). In addition, Hispanics
were still much more likely to rate each hospital
more positively than whites.

Limitations
Our study had several limitations. First, HCAHPS
measures are subjective, so it is difficult to determine
the differences between patients’ expectations and

Table 1. Characteristics of Hispanic and Non-
Hispanic White Patients Admitted to U.S.
Hospitals

Characteristic

Ethnicity

Hispanic White

No. of patients 238,310 3,626,628

Age, years

Less than 65 66.5 49.2

65–69 8.2 11.2

70–79 15.2 21.6

80 or more 10.1 18.0

Sex, %

Male 30.6 38.7

Female 67.6 60.7

Education, %

Less than high school 32.3 12.2

High school graduate or GED 27.1 32.4

Some college or beyond 40.5 55.4

Overall health, %

Excellent 21.0 12.9

Very good or good 54.5 58.8

Fair or poor 24.5 28.3

Reason for admission, %

Maternity care 24.2 10.7

Medical 41.7 48.0

Surgical 28.8 34.9

Missing 5.4 6.3

Note: GED 5 General Education Diploma. These are respondents of the
HCAHPS survey in 2009 and 2010. Some percentages do not sum to
100 because of rounding. All differences between Hispanics and
whites were significant (p , .001).

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Copyright 2018 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

differences in hospital quality using these measures;22

however, it is still critically important to examine
patient experience because the underlying expect-
ations are a part of how a patient experiences care.
Second, the HCAHPS survey only has a 30% response
rate. Although it is possible that the views of the
respondents do not necessarily reflect those who did
not respond to the survey, the HCAHPS survey has
undergone extensive testing that shows results are not
substantially affected by nonresponse bias. Third, we
were unable to evaluate Hispanic ethnicity in more
detail because Hispanics represent people frommany
Latin American countries, with different cultural
norms, lifestyles, varying degree of economic circum-
stances, and significant differences in overall health
depending on the country of origin. Fourth, it is
possible that insurance status (or lack of insurance
status) may influence how patients experience care.
Differences in insurance statusmay thus partly explain
some of the differences in patient satisfaction between

whites and Hispanics. Next, we did not have in-
formation on exact reasons why patients were
admitted beyond the type of ward so we were unable
to adjust for severity and type of admission. Finally, our
data were collected before the start of the Hospital
VBP program. However, we have no reason to believe
that our results would changebecause recent evidence
showed that HCAHPS scores have only risen slightly
over the last several years, and the introduction of the
VBP program had no effect on improving patient
experience.10,23

Discussion
Across U.S. hospitals, we found surprisingly few
meaningful differences in patient experience be-
tween Hispanic and non-Hispanic white patients. In
fact, Hispanics generally reported more positive
experiences than non-Hispanic white patients across
most measures of patient experience as reported

Table 2. Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients,
Overall and Adjusted by Patient Characteristics

HCAHPS measure

Unadjusted Adjusted for patient characteristics

Hispanic White Difference p-value Hispanic White Difference p-value

Overall satisfaction

Recommend hospital 74.2% 70.9% 3.4% ,.0001 74.1% 70.9% 3.3% ,.0001

Best rated hospital 72.9% 65.9% 7.1% ,.0001 72.5% 65.9% 6.6% ,.0001

Communication

Communication with doctors 81.8% 78.2% 3.7% ,.0001 79.9% 78.3% 1.6% ,.0001

Communication with nurses 76.4% 75.0% 1.4% ,.0001 75.0% 75.1% 0.0% .94

Communication about medications 63.4% 57.5% 5.9% ,.0001 60.1% 57.7% 2.4% ,.0001

Clinical management

Adequate staff services 64.9% 60.2% 4.8% ,.0001 61.0% 60.4% 0.6% .03

Pain management 59.0% 50.3% 8.6% ,.0001 54.1% 50.6% 3.5% ,.0001

Discharge information 80.0% 79.0% 1.0% ,.0001 78.5% 79.1% 20.6% .003

Hospital environment

Quietness of hospital environment 63.4% 53.0% 10.4% ,.0001 58.0% 53.3% 4.7% ,.0001

Cleanliness of hospital environment 69.8% 69.4% 0.5% .1304 68.6% 69.5% 20.9% .004

Note: Multivariable regression models were used to adjust differences between Hispanic and white satisfaction scores for correlation within hospitals, as
well as for age, sex, health status, education, primary language spoken at home, and source of admission. Differences may not match values precisely
because of rounding.

296 September/October 2018·Volume 40·Number 5 www.jhqonline.com

Original Article

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through the HCAHPS survey. However, the gap
between Hispanic and white patient experience was
substantially smaller among patients with at least
some college education than among those with less
education.

It is reassuring that there are no meaningful
differences in the report of patient experience within
the given U.S. hospitals. Even in the area of
communication, where concerns about language
proficiency or cultural competency may be more of
an issue, we found that Hispanic patients generally
reported more positive experiences than non-
Hispanic patients.

These results are consistent with a well-known
observation called the “Hispanic paradox.” Despite
having, on average, lower socioeconomic status and
less access to education and health services than non-
Hispanic whites, Hispanic health status is closer or
even better than non-Hispanic whites.24 Previous
work has shown that Hispanics have longer life
expectancy than non-Hispanic whites25 and also
lower mortality rates in seven of the 10 leading
causes of death in the United States.26

There are some plausible explanations for why
Hispanics report better satisfaction than whites. First,
there is a strong relationship between an individual’s

overall health status and health experience: individ-
uals with better health status are more likely to be
satisfied with the health system.21,27 Part of what may
explain the Hispanic paradox is that Latinos that
migrate into the United States tend to be younger
and healthier than the average population.28 In
addition, when they become severely ill, a large
number of Hispanics return to their home countries
to get treatment and often stay there until the end of
their lives, which do not get recorded officially byU.S.
figures.29 Second, it is possible that differences in
patient experience reflect the underlying expect-
ations of care. It may be that Hispanics on average
have different expectations for the care they receive
in hospitals. Differing expectations of care is sup-
ported by the fact that patients with higher educa-
tional attainment report more negative evaluations
of care across both races. This may be due to
educated patients having higher expectations for
how they should be treated, which translates to lower
evaluations of hospital experience.30-32

However, although it is reassuring that Hispanic
and non-Hispanic whites report comparable experi-
ences, it is concerning that Hispanic patients are, on
average, receiving care at hospitals that perform
worse on measures of patient experience for all

Figure 1. Within-hospital differences in patient experience between Hispanic and non-Hispanic white
patients, adjusted for patient characteristics. Note: The difference in performance score between Hispanics
and whites was statistically significant for all measures (p , .001).

Journal for Healthcare Quality September/October 2018·Volume 40·Number 5 297

Copyright 2018 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

patients. Previous work has shown that hospitals with
high patient experience also have better outcomes,
including lower 30-day mortality and readmission
rates after admission for acute myocardial infarction,
heart failure, and pneumonia.2 Thus, the fact that
Hispanics are generally receiving care at lower
performing hospitals raises concern, especially con-
sidering that they are already less likely to receive
timely care compared with non-Hispanic
patients.15-17

Our study adds to a growing body of literature
examining patient experience by race and ethnic-
ity. To our knowledge, this is the first national study
examining patient experience of Hispanic patients
across all U.S. hospitals that reported HCAHPS.
Previous work by Goldstein and colleagues evalu-
ated a sample of U.S. hospitals that chose to
voluntarily report patient experience scores and

found similar results.33 These results are also
consistent with a recently published study that
showed black patients reported comparable pa-
tient experience to white patients in U.S. hospitals,
and black patients were also more likely to receive
care at hospitals with lower patient experience
scores for all patients.21 Therefore, our findings are
consistent with a broader set of studies suggesting
that minority populations are more likely to receive
care at hospitals with poor quality than white
patients rather than differential treatment within
the same hospital.34,35

Conclusions
Hispanic patients on average reported comparable
or even better patient experience than non-Hispanic
white patients within a given U.S. hospital. However,

Table 3. Adjusted Differences in Patient Experience Between Hispanic and Non-Hispanic White
Patients

HCAHPS measure Overall difference
Within-hospital component

of difference
Between-hospital component

of differencea

Overall satisfaction

Recommend hospital 3.3%** 5.5%** 22.3%

Best rated hospital 6.6%** 9.2%** 22.6%

Communication

With doctors 1.6%** 3.4%** 21.8%

With nurses 0.0% 3.3%** 23.3%

About medications 2.4%** 4.1%** 21.7%

Clinical management

Staff services 0.6% 3.9%** 23.3%

Pain management 3.5%** 5.5%** 22.0%

Discharge information 20.6% 1.0%** 21.6%

Hospital environment

Quietness 4.7%** 7.3%** 22.6%

Cleanliness 20.9%* 0.6%** 21.4%

Note:Multivariable regression models were used to adjust differences between Hispanic and white satisfaction scores for correlation within-hospital, as well
as age, sex, health status, education, primary language spoken at home, and source of admission.

a The between-hospital component of difference was determined by subtracting the within-hospital component of difference from the adjusted overall
difference. The percentages in this column indicate the average difference in the performance scores on satisfaction between hospitals where Hispanics
on average receive care and hospitals where whites on average receive care. Significance of this component cannot be assessed.

*p , .01, **p , .001.

298 September/October 2018·Volume 40·Number 5 www.jhqonline.com

Original Article

Copyright 2018 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

it is still concerning that Hispanics are, on average,
receiving care at lower-performing hospitals.

Implications
Our work suggests that efforts targeting minority
populations may be more effective if they focus on the
hospitals that predominantly care for minority patients.

Authors’ Biographies

Jose F. Figueroa, MD, MPH is a research specialist at the Harvard
T.H. Chan School of Public Health in Cambridge, MA. J. F. Figueroa also
practices medicine at the Brigham and Women’s Hospital and Harvard
Medical School.

Kimberly E. Reimold, BA is a research assistant at the Harvard T.H. Chan
School of Public Health in Cambridge, MA. She works with Dr. Ashish Jha’s
research team.

Jie Zheng, PhD is a statistician at the Harvard T.H. Chan School of
Public Health in Cambridge, MA. She works with Dr. Jha’s research team as
well.

Endel John Orav, PhD is a statistician at the Harvard T.H Chan School of Public
Health and Brigham and Women’s Hospital. He frequently works with members of Dr.
Jha’s research team to determine the best methods and refine analytical plans.

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