Patients' Perspectives of Surgical Safety: Do They Feel Safe?

INTRODUCTION

Since To Err is Human: Building a Safer Health System was published in 1999, eliminating patient harm has been an area of increased focus.¹ Surgical safety initiatives, including time-out, surgical safety checklists (SSCs), and debriefings, have been shown to reduce errors, improve outcomes, and increase quality of care metrics.^2-4 SSCs also improve teamwork and communication, promoting a culture of patient safety.^3,5-7 The development of effective SSCs was influenced by earlier work in the airline industry where checklists provided a robust tool to promote adherence to standard safety practices.⁸ While checklists are highly effective with the rigid interface of pilot and machine, adapting them to patient care processes adds another level of human complexity.^9,10 Many of these processes require repetitious questioning of patients through different phases of care and if misinterpreted may be seen as a failure of communication or as provider incompetence, leading to dissatisfaction with the surgical experience.¹¹

The healthcare industry has increased its focus on patient satisfaction as a quality metric.^12-16 The future direction for healthcare payments is to link these patient perception metrics to reimbursement.^13,17 Additionally, public reporting of patient satisfaction may lead to bias in physician selection by future patients.¹⁸ Many factors influence patient satisfaction, and perceptions of safety may have a prominent role.^19,20 Rathert et al suggested that a patient's perception of safety is greatly influenced by the processes of care.²¹ While we search for means to increase patient satisfaction, we do not know patients' perceptions of surgical processes in current surgical safety practice. Therefore, patient safety perceptions in surgery need to be defined.

This study aimed to determine patient perceptions of surgical safety with an emphasis on surgical team interaction throughout the phases of care. To our knowledge, no previous reports on surgical safety initiatives from the patient's perspective have been published.

RESULTS

Surveys were distributed to 345 patients, and 102 (29.5%) responded. The demographics of the responders were similar to the overall hospital patient population demographics in terms of race, income level, and education level (Table 1). The majority of responders were female (62.7%), married (62.7%), of white race (77.5%), and had an annual household income level <$75,000 (72.6%). Sixty-six percent of patients had laterality involved in their surgical procedure, and only 11.8% had undergone their first surgery. Thirteen percent of patients felt that their current procedure was necessary because of a prior complication.

Survey questions were grouped according to the phase of care or team member interaction (Table 2). Overall, patients' perception of surgical safety was high, as evidenced by mean scores between 6 (agree) and 7 (strongly agree) for questions 1-19 (Figure 2). Examples include “I felt safe the day of my surgery” (6.53 ± 0.72) and “On the day of the surgery, the surgical team's top priority was my safety” (6.51 ± 0.81). The lowest score in the survey was for question 20, “Mistakes rarely happen during surgery” (5.39 ± 1.51).

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Figure 2.

Mean survey responses by question. Responses were selected from a 7-point Likert scale in which 1 = strongly disagree and 7 = strongly agree.

To determine whether patient demographics played a role in survey responses, each question was analyzed according to demographic subgroups. No differences in ratings dependent on sex, race, or education level were observed. Patients undergoing their first surgery were more likely to respond with a lower score to the statement, “On the day before the surgery, I felt confident about my safety” (6.03 vs 6.68, P=0.016). Patients with higher income levels had a significant decrease in safety perceptions for 5 of the 20 questions (Table 3), with a stepwise decrease in responses as income increased.

Seventeen participants attended qualitative feedback sessions. The most common themes positively and negatively impacting the perception of patient safety are listed in Table 4. The surgeon's personal interaction with the patient, especially in the preoperative area, was the most important factor positively influencing patient safety perceptions. This impact is demonstrated by direct patient quotes: “It made me feel really safe when my doctor came in before my surgery, talked to me, and introduced himself to my family” and “…the doctors came in, explained what was going to happen, what I could expect, and that put me at ease.”

Miscommunication on the surgical ward was the most common negative influence on patient perception of safety. One patient said, “…the surgical team was excellent, but my hospital stay once I got to my room, it just fell through the roof…it was like there was no communication.” The focus groups also identified a high burden of work for nurses and a feeling of abandonment after arriving at the surgical ward. Our hospital is exploring this area of opportunity for enhancing our patients' sense of safety.

DISCUSSION

At our institution, surgical patients have an overall high sense of safety, especially during the immediate operative period. Other institutions have similarly demonstrated that surgical patients report high levels of satisfaction with their care.^23-25 Patients realize the priority that surgical safety has among the surgical team members but are generally unaware of the measures put in place to improve surgical safety, such as checklists. However, patients are not troubled by repetitive questioning of personal information and surgical procedure. The global high responses to the survey questions were surprising, as we anticipated that patients would be more critical of the healthcare system in the current economic and healthcare climate. Physician trust and patient communication had the greatest impact on patients' perception of their safety and are not directly influenced by more modern patient safety initiatives.

Relatively few studies have addressed safety from the patient's perspective, and we could find none specifically addressing surgical patients. During the 2000s, many advances in surgical safety have been implemented, and it is important to understand how our patients perceive these processes.^15,19 Our study provides a baseline and a new insight into patients' perception of healthcare.

Overall, our patients' perception of safety was high. Interestingly, in our study we found that initial surgical experience and patient income were the only significant factors that negatively influenced patient response. These findings are not new. Evans et al similarly reported that patients with a higher income were more likely to feel unsafe in the hospital setting.²⁶ This inverse relationship between income level and perception of safety is interesting and deserves further explanation. Our data suggest that this finding is not a result of education, as the analysis for education levels showed no significant difference in safety perception within this group. Understanding the demographic-specific impact on patient perceptions will help providers and hospitals improve patient experiences in the future.

Patients value safety, and reports indicate that patients assume processes are in place to ensure their safety.^27,28 The focus group arm of our study explored this theme further and found that the level of trust and communication had the greatest impact on patient safety perceptions. This finding is supported by Wolosin et al who showed that patients' perceptions of safety are influenced by information sharing and that communicating safety practices to patients could bridge the gap between patients' perceptions of safety and reality.²⁹ Indirectly, we stumbled across this concept in our focus groups in which we provided a standardized presentation about our institution's SSC. The presentation provided an overview of the conception, implementation, and performance of the checklist as patients experienced it during the process of surgical care and how it can improve patient safety. Our focus group facilitator found that most participants were unaware of the SSC and other safety initiatives during the processes of care, suggesting that implementation of a more visible or familiar process may result in greater patient participation and improve the experience and perception of patient safety. One such process could incorporate technology from our daily lives such as Quick Response codes. Our institution previously explored the concept of technologic aids in the operating room and found that these processes allow greater participation for the surgical team and patient.³⁰

Deficient areas defined by the patients are similar to areas that healthcare providers and hospitals have identified as needing improvement.^31-33 Factors contributing to patient safety incidents vary across hospital settings, as highlighted in a 2012 review.³⁴ Team factors and communication system failures were found to be the most common causes in the surgical setting. Scott et al showed that patients feel unsafe during transitions of care.³⁵ Our study reflects our patients' perception of this defect upon transfer to the ward units, and it has been identified as an area in need of quality improvement. The level of communication between patients, surgeons, and nurses influences how patients perceive the quality of their care.³⁶ Black et al found that surgical patients who reported better levels of communication and trust in their doctor were 30% less likely to report a complication.³⁷ Thus, improving how patients perceive the level of communication through all phases of care could have a significant impact on hospital quality metrics.

The limitations of our study include a low response rate and lack of a previously established and validated survey. Participation was anonymous and voluntary, with surveys returned in prepaid envelopes. We had no way to control for participation rates and no method for contacting patients who did not respond to increase our response rate. However, the demographics of responders were similar to the overall institution's patient population, so our sample is considered to be representative of our institution as a whole. To overcome the lack of a validated survey, we involved a multidisciplinary team participating in all phases of care to develop and revise critical elements of safety during phases of care. All team members reviewed and agreed on the survey questions prior to implementation.

During our busy work lives, we must not lose sight of the importance of the humanistic bond within the physician-patient relationship.^37,38 Patients with high levels of trust feel safer,³⁹ and further studies are needed to identify specific factors that affect their perceptions.

CONCLUSION

Our baseline survey established that patients have a high perception of safety within the current surgical setting. While using checklists and other tools improves adherence to the process of safety initiatives, clinicians must focus on what patients value in their perception of safety––a physician-patient relationship that fosters trust and communication.