MAY 1989, VOL. 49, NO 5
Discharge Surveys A QUALITY ASSURANCE METHODFOR AMBULATORY SURGERY Mary Williams, RN; Sherryl P. Brett, RN ischarge surveys are one way to monitor the quality and appropriateness of care in an ambulatory surgery setting. They give valuable information that can be incorporated into a quality assurance plan. Because time is a major consideration, ambulatory surgery centers must continually explore methods of monitoring quality assurance in a comprehensive manner. Many patients who would have traditionally spent several days in the hospital for surgery are now in and out of the hospital in four hours or less. There is less time to observe the patient for complications, document the care given, give
postoperative instructions, identify problems, and evaluate the quality and appropriateness of care provided. The Joint Commission on Accreditation of Healthcare Organizations has addressed quality assurance in ambulatory settings in its accreditation process.' Hospital-sponsored ambulatory care must meet the same standards of quality that apply to the inpatient population. Ambulatory care departments are required to have a planned and systematic process for monitoring and evaluating quality and appropriateness of patient care and for resolving identified problems.
Mary Williams,M, BSN, is the nurse manager, special medical services, Pitt County Memorial Hospital, Inc, Greenville,NC. She was the assistant head nurse, ambulatory surgical unit, pltt County Memorial Hospital, Inc, when this article was written. She earned her bachelor of science degree in nursing from East Carolina University, Greenville,NC.
Sherryl P. Brett, RN,is the assistant head nurse, ambulatory surgical unit, Pitt County Memorial Hospital, Inc, Greenville, NC. She was the quality assurance representative,ambulatory surgical unit, Pitt County Memorial Hospital, Inc, when this article was written. She earned her associatedegree in nursing from Roanoke-Chowan Technical College, Ahoskie, NC. 1371
MAY 1989, VOL. 49, NO 5
Evaluation of patient satisfaction is essential, but it cannot be the only mechanism of evaluating quality patient care. Literature Review: Patient Satisfaction
Commission, patient outcomes must be the major focus of a quality assurance program!
atient satisfaction has been well documented as an essential component of evaluating care provided in ambulatory surgery settings. Many methods have been used to gather data related to patient satisfaction. They include patient interviews, surveys distributed to patients while in the surgery unit, telephone followups after discharge, and questionnaires, either mailed or given to patients to be completed at home and returned. One study pointed out that patient satisfaction with nursing care can positively affect the patient’s physical and emotional equilibrium, thus contributing to positive patient outcomes? Patients who are satisfied with their health care are more inclined to take an active role in their care and recommend the unit to others. Although evaluation of patient satisfaction is essential, it cannot be the only mechanism of evaluating quality patient care. One researcher cautions against equating patient satisfaction with quality patient care? Reports of dissatisfaction should be evaluated, but some patient dissatisfaction with care may be expected when patients have to learn self care. In addition, some factors of ambulatory surgery are uncontrollable. The scheduling process in hospital-integrated ambulatory surgery units that use the same operating rooms for both outpatients and inpatients is often unpredictable. Sometimes patients encounter extended waiting periods before surgery which contribute to their dissatisfaction. Also, the patient who drinks a cup of coffee before arriving for surgery has to have his or her procedure delayed to decrease the risk of aspiration. This ensures a better outcome for the patient, but it may lead to patient dissatisfaction. Patient satisfaction is only one aspect of evaluating quality of care. According to the
Discharge Survey: Development
s part of our quality assurance program at Pitt County Memorial Hospital, Inc, Greenville, NC, we developed a multidisciplinary discharge follow-up survey to assess the quality and appropriateness of care delivered. We found that patients’ responses are extremely valuable in planning and evaluating patient care. The survey originally was implemented in August 1985 as a telephone survey. It consisted of brief questions related to patient satisfaction, recovery status, and postoperative complications. Patients were called within a week of discharge during the operational hours of the unit (Monday to Friday, 6 AM to 6 PM). After a trial period of several months, we found this method ineffective. The telephone follow-up was extremely time consuming, and the actual contacts were fewer than 20%. We believe the low number of contacts was because many of the people worked during our operational hours. After reviewing written surveys used by other outpatient surgery centers, the ambulatory surgical unit staff developed a discharge follow-up form, which was implemented in November 1985 (Fig 1). Questions relate to patient satisfaction, anesthetic problems, surgical complications, discharge instructions, and waiting periods before surgery. Space for comments and patient suggestions are provided on the survey.
Discharge Survey: Implementation
atient volume averages 300 admissions per month; 55%are outpatient surgery,and 45% are same-day admission surgery patients,
MAY 1989, VOL. 49, NO 5
Ambulatory Surgical Unit Discharge Follow-Up Form Thank you for choosing our facility. In an attempt to continually upgrade our quality of care, we would like you to return this questionnaire in the enclosed stamped addressed envelope. Patient’s name: Telephone # Date of surgery: Surgeon: Surgery performed.
1. Were you treated courteously at all times? Yes If no, explain:
2. Were your questions answered adequately? Yes - No If no, explain:
3. Have you experienced any problems resulting from your surgery (eg, fever of 100.5 OF or more, ex-
cessive pain, abnormal bleeding or drainage, shortness of breath, or chest pain)? Yes If yes, explain:
4. Have you called your physician or come to the emergency room because of any problems resulting from your surgery? Yes
5. Have you experienced any minor discomforts resulting from your surgery or anesthetic (eg, nausea, No hoarseness, sore throat, cough, muscle aches, headache)? Yes If yes, explain:
6. Were pain medications prescribed for you helpful? Yes If no, explain:
7. Were your discharge instructions clear? Yes If no, explain:
8. How long was your waiting period before surgery?
9. In your opinion, was the waiting period before surgery too long ? about right
10. Did your nurse adequately explain what you should expect during your ambulatory surgical unit stay? Yes No If no, explain: 11. Would you use our services again or recommend our unit to others? Yes
12. How could we have made your visit more pleasant?
13. Other comments:
(Adapted with permissionfrom Pitt County Memorial Hospital, Inc, Greenville, NC)
MAY 1989, VOL. 49, NO 5
who are admitted as inpatients after surgery. Patients who undergo outpatient surgery receive copies of the survey when they are discharged. The survey includes the following instructions. Complete the survey one week after discharge. (This allows us to receive more data on wound infections and other postoperative complications.) Complete the survey as accurately as possible. (The nurse reviews the form with the patient and shares how information is
used.) Return the survey in the self-addressed, postage-paid envelope provided. On return, the survey is reviewed by the quality assurance representative or staff nurse. If any data in the survey warrant immediate attention, the quality assurance representative calls the appropriate individual or department.The patient receives a follow-up telephone call regarding any action that was taken. All nursing actions are documented on the back of the survey and filed in the unit. If the patient experienced a postoperative complication, he or she is contacted by telephone to ensure that appropriate actions were taken and that the physician was notified.The medical record is reviewed to determine if appropriate discharge instructions were given by the nurse and if the patient met discharge criteria. In all instances of patient complications following discharge, we found that the patient met discharge criteria and that the patient was made aware of whom to contact should an emergency or problem arise. If a patient develops a wound infection or other nosocomial infection, we send a copy of the discharge follow-upform along with nursing actions to the epidemiology department. If indicated, the physician is contacted and informed of any problems or complications. All information is compiled and analyzed monthly by the quality assurance representative and tallied on a tracking calendar, using a descriptive statistical technique (Fig 2). On a quarterly basis, a narrative analysis is completed that analyzes the statistical data found on the tracking calendar. The analysis form includes specik problems or issues encountered by the patient and family, opportunitiesfor improvement, 1376
actions taken, and evaluation of previous actions taken (Fig 3). The tracking calendar and other quality assurance monitors are included in the quarterly report. The quarterly report is reviewed by the executive committee of the ambulatory surgery unit as well as the nursing and hospital quality assurance committees.
Data Analysk: 1987 to 1988
he surveys tell us what patients value. Prompt, courteous, and effective care are always at the top of the list. The overall percentage of patients who were satisfied with all aspects of their care was 84%. We had a 43% return rate on the surveys. Our goal is to maintain an 85% or greater total patient satisfaction and a 40% return rate. Sixteen percent of patients were dissatisfied with some aspect of their care in the ambulatory surgery unit or offered suggestions to improve care. The major dissatisfactionwas the waiting period before surgery (9%). Another major dissatisfaction was the lack of privacy and noise level within the ambulatory surgery unit. Our unit is an open unit with curtains separating eight bedspaces. Patients of all ages are prepared and recovered in the same area. Other information obtained from the survey includes anesthetic side effects and surgical complications. The major anesthetic side effect was sore throat. Very few surgical complications were reported. Overall, feedback received on the survey is extremely encouraging and shows that the patients are satisfied with most of the care they receive. We have changed, or are in the process of changing, the following specific areas as a result of patient dissatisfaction. Preoperative changes. Patients are called the afternoon before surgery and informed of their surgery time and asked to amve one to two hours early to allow for preparation. A map is provided on our new “Patient Instruction Brochure” giving directions to our unit and other departments. Patients are informed on preadmission of possible unforseeable delays and emergencies that may delay their surgery. Ambulatory surgery unit staff
MAY 1989, VOL. 49, NO 5
Quality Assurance Tracking Calendar Department: Unit representative:
Plan date: Date reviewed:
Indicators/sample # and frequency
I. Volume 1. # sent out 2. #returned 3. return percentage 11. Quality/appropriateness 1. Patients 100%satisfied with services they received 2. Patients who expressed dissatisfaction with our services 3. Patients who expressed dissatisfaction with the waiting period 4. Patients who experience minor problems after surgery a) nausea and/or vomiting b) low grade fever c) muscle aches d) sore throat e) cough f) dizziness g) hoarseness h) mild pain i) mild bleeding or drainage j) other 5. Patients who experienced complications after surgery a) infection b) excessive bleeding c) excessive pain d) pulmonary e) other
(Adapted with permksion from Pitt County Memorial Hospital, Inc, Greenville, NC) 1377
MAY 1989, VOL. 49, NO 5
I. Data assessment: Iidicator: A follow-up method is needed to assist the staff in determining the effectiveness of the current discharge criteria and to evaluate the quality of care delivered. Monitored
Criteria A discharge follow-up form along with a self-addressed stamped envelope is given to all surgery patients before discharge to assist the staff in evaluating the quality of care rendered and to determine the patient’s condition after surgery. 111. Opportunities for improvement:
V. Effectiveness of action/follow-up: (Adapted with permissionfrom Pitt County Memorial Hospital Inc, Greenville, NC)
members and anesthesiologists inform patients of possible anesthetic side effects. Patient comfort changes. Plans have been made to carpet part of the unit to decrease the noise level. Magazines are now provided for patients by volunteer services. A portable radio with earphones is provided for patient use in the OR if desired (local anesthesia cases only). The bathroom tissue roller was changed to an easier rolling type. Many patients requiring enemas and/or douches before surgery now administer their own at home before admission. Instruction sheets on how to administer the enema and/or douche are given and explained to the patient on preadmis1378
sion. This alleviated the problem we had with just one bathroom and lack of privacy. A policy was written to indicate that bottlefed infants could have clear liquids until 2 AM instead of having to be NPO after midnight. Waiting area changes. A receptionist is now available in the waiting room to inform families of progress and answer questions. A new thermostat was installed in the waiting room so that temperature could be regulated. Postoperative changes. Meals for postoperative patients were changed to soup and sandwiches instead of full meals. Specialty discharge instruction sheets were written on various surgeries. We have also revised
our generic discharge self-care instruction sheet to more effectively inform the patient/family of minor anesthetic and surgical discomforts and problems that necessitate contacting the physician. Survey changes. We have revised our discharge quality assurance monitor to more objectively assess the patient responses to the questions in the questionnaire.
m u s e of subsequent surveys we have received since compiling the data for this article, we are now using a wagon to transfer pediatric patients to the OR. We have received positive comments on our discharge follow-up form, for example: “We were very womed about having our 2 year old confined before surgery. The staff allowed him to be up and about. I appreciated that he was taken away in a wagon. Alex enjoyed being in the wagon, and I didn’t feel so bad about sending him to surgery.” During preadmission teaching, we are now teaching crutch walking techniques to orthopedic patients who will need crutches postoperatively. This change has greatly enhanced the patient’s recovery time and understanding of proper use of crutches. The patient does not have to learn to use crutches after receiving general anesthesia. We now submit discharge forms to the marketing department that reflect excellent standards of care, and our staff receives balloons and special treats. This has been a real boost to 0 the staff morale. Notes 1. Joint Commission on Accreditation of Healthcare Organizations, AMHI88 Accreditation Manual for Hospitals (Chicago:Joint Commission on Accreditation of Healthcare Organizations, 1987) 7 1. 2. P B Gamotis et al, “Inpatient vs outpatient satisfaction:A research study,”AORNJouml47 (June 1988) 1421-1425. 3. L R Eriksen, “Patient satisfaction: An indicator of nursing care quality?” Nursing Management 18 (July 1987) 31-35. 4. AMH/88 Accreditation Manualfor Hospitals, 7 1. Suggested reading Abramowitz, S; Cote, A A Berry, E. “Analyzing patient 1380
satisfaction: A multianalytic approach.” Journal of Qualiy Assurance 13 (April 1987) 122-130. Bradley, D K. “Quality assurance in ambulatory health care facilities.” Journal of Qualiv Assurance 7 (Summer 1985) 11. Brett, S; Williams, M. “Discharge surveys: A method of quality assurance for outpatient surgery.” Perspectives on Patient Care (Greenville, N C Pitt County Memorial Hospital, Inc, 1988). Buske, S M. “A quality program for ambulatorysurgical services.” In Ambulatory Surgety: Developing and Managing Successful Programs,ed L A Burns, 6381. Rockville, M d Aspen Systems Corp, 1984. Icenhour, M L. “Quality interpersonal care: A study of ambulatory surgery patients’perspectives.”AORN Journal47 (June 1988) 1414-1419.
AIDS Guidelines Available for Schools of Nursing A set of guidelines has been published to help schools of nursing understand various aspects of acquired immune deficiency syndrome (AIDS). AIDS Guidelinesfor Schools of Nursing includes guidelines on general policy, clinical experience for faculty and students, and prevention of transmission of the human immunodeficiency virus (HIV). It was published by the National League for Nursing (NLN). These guidelines are available to schools of nursing so that they can draft policies that address the moral, legal, and educational issues they face with the AIDS crisis. Institutional policy guidelines cover institutional committees, handicapping conditions, admissions, access to university facilities and campus activities, housing, health care, and support services. The clinical experience guidelines outline education, supervision, and counseling procedures designed to allay students’ fears and ensure the safety or both students and patients. They follow the Nursing Code of Ethics. The guidelines for the prevention of HIV transmission are similar to the recommendations by the Centers for Disease Control, Atlanta. To order the free guidelines, contact the communications coordinator at (800) 847-8480 or, in New York state, (800) 442-4546.