Patients and their families were treated with “callous indifference.” Water was left out of reach. Soiled bed sheets weren’t changed, sometimes, for months.
The abuses that took place between 2005 and 2008 in an England hospital shocked the country. A 139-day public inquiry revealed that there were many signs leading up to the abuse. If acted on, they could have prevented hundreds of deaths, according to media accounts. The staff satisfaction survey at the Mid Staffordshire National Health Service (NHS) Trust was among the red flags. The trust ranked in the worst 20% for team work, supervision, and staff involvement, among other indicators.
Staff satisfaction surveys are now seen as such an important “barometer of what’s going on” at UK hospitals that regulatory agencies now incorporate the data in their inspections, according to Michael West, a senior fellow at the King’s Fund who was instrumental in developing the NHS staff engagement survey. “You can look over time to see whether nationally health care organizations are improving, and you can also make comparisons across organizations,” says West.
England’s national staff survey has spurred important policy and work culture changes. The government strengthened reporting and prosecution procedures relating to violence against health workers in response to high percentages of survey respondents saying patients had physically assaulted them. Additionally, “there has been a real push at the national level to increase the number of staff appraisals,” says West. That’s paid off. The percentage of staff indicating they had an appraisal in the last year went from 76 to 84% between 2011 and 2013. More work is to be done, however, as the percentage of staff indicating the appraisal helped them do their job remained unchanged at 55%.
How staff satisfaction is currently measured in Canada
Unlike in England, there is little standardization and transparency when it comes to staff satisfaction surveys in Canada.
In Ontario, all hospitals have been required to survey their employees at least every two years since 2010. But what questions they ask is largely up to hospital managers and the data aren’t publicly reported. (The government does provide guidance on the surveying process, however.)
In Alberta, all staff at hospitals and long-term and community care facilities are invited to fill out a standardized staff engagement survey every two years, says Robert Armstrong, acting vice president of human resources at Alberta Health Services. The “high level” results are available for public consumption, but hospital-level scores are not.
Nationally, Accreditation Canada requires staff satisfaction surveys every two years. (The body accredits all hospitals and most long term care facilities across the country.) While it provides a standard tool, institutions can choose to distribute their own survey. The results aren’t publicly reported, however, according to Geneviève Brisson, communications specialist with Accreditation Canada.
Staff satisfaction is linked to the quality of patient care
As Mary Ferguson-Paré, a retired hospital nurse leader, puts it, “You can’t ask staff to treat patients in a way that is going to result in patients feeling involved, listened to and supported if staff aren’t experiencing the same things themselves.”
The evidence gives credence to this point. Comparing data from the standardized NHS staff satisfaction surveys to mortality rates, a 2013 study found that facilities with more staff saying they would recommend their centre had slightly lower mortality rates.
An examination of survey data gathered from nearly 100,000 nurses in the U.S. revealed hospitals where nurses’ reported high job satisfaction also had higher percentages of patients saying they would recommend that hospital to others.
When it comes to physician satisfaction, previous studies have found that satisfied physicians were less likely to prescribe unsafe drugs and had more satisfied patients.
Certain aspects of a workplace culture are especially revealing. Michael West’s research, for instance, has found correlations between lower infection rates and staff saying they can contribute to improvements at work.
Should Canada follow England’s example and publicize staff satisfaction survey results?
Interestingly, in Ontario, according to a 2011 government survey, 91% of hospital leaders want a standardized staff satisfaction survey so they can make peer-to-peer comparisons. Despite this interest, Ontario’s Ministry of Health and Long-Term Care (MOHLTC) spokesperson David Jensen could only say that a standardized tool “may become part of a future approach.”
Not all hospital managers are convinced of the utility of standardization and public disclosure, however. Emma Pavlov, vice president of human resources at University Health Network fears a standardized survey would be too generic. She wants to be able to poll staff member’s opinions on management and quality initiatives specific to the UHN, she explains.
It’s possible, of course, to implement a standardized survey that gives room for site-specific questions. In England, for example, NHS trust managers add their own questions to the end of the national survey, says West.
In Pavlov’s opinion, “10 or 12” standardized questions could flag issues for the government and public, but she worries more than that could take away from staff’s time and willingness to answer site-specific questions.
Armstrong, meanwhile, thinks the results of staff satisfaction surveys could be misinterpreted by the public if they’re widely disseminated. Low satisfaction scores don’t necessarily highlight problems, he explains. Scores can drop, for instance, “when a new manager comes in and starts to address issues that were unaddressed and gets a negative reaction from certain staff.”
Renée Légaré, executive vice president of human resources at The Ottawa Hospital, is, on the other hand, “all in favour” of standardized surveys and transparency. (Currently, however, the hospital’s survey results aren’t publicly available. This is true of all Ontario hospitals, according to Hazel Harding, communications advisor at The Ottawa Hospital.)
“Any standardized survey could give us 20 additional questions that could be tailor made to the respective hospitals,” says Légaré, who isn’t concerned a combination standard and localized survey would be overwhelming for staff. “Staff appreciate the opportunity to speak up, I don’t think there would be an issue,” she says.
Linda Silas, president of the Canadian Federation of Nurses Unions, goes further. In addition to staff surveys, other indicators of staff safety, including numbers of violent incidents and occupational health and safety reports, should be publicly available, she says. By bringing this information “to the public eye,” health workers will be better positioned to demand protective equipment and measures – protections health workers have to “argue and negotiate for” more than workers in other sectors, she argues.
When it comes to opinions on mandatory reporting of staff satisfaction data, it’s worthwhile to look at West’s experience in implementing the NHS survey in 2003. At first, many hospital managers said “this is more work, it’s intrusive, it’s not appropriate,” according to West. But as the results came in and important policy discussions took place, the mood changed. “There’s no resistance now to the survey and I think people recognize that it’s very helpful,” he says.
Reporting isn’t meaningful without accountability
As the Stafford example shows, publicly disclosing survey results itself is not enough. Indeed, two publicly reported staff surveys revealed low, and slipping, scores at the Mid Staffordshire Trust during the years the abuses took place. After the inquiry, a national commission was created in the UK to monitor and respond to staff and patient survey data, whistleblower statements and other information. Clearly, strong procedures need to be in place not just to gather, but also to act on, staff satisfaction data.
For its part, Ontario, under the Excellent Care For All Act, demands accountability on staff satisfaction surveys by requiring all hospitals to address shortcomings identified in the surveys in their quality improvement plans, according to Jensen. Just as public reporting isn’t helpful without action, however, accountability is reduced without standardization and public scrutiny. Ontario’s lack of a standardized staff survey means it is difficult to compare one hospital to another, and to recognize hospitals that are falling behind. Furthermore, only hospitals are required to report staff satisfaction survey results to the government. Staff satisfaction surveys at long-term and community care organizations could serve as an important accountability tool if subject to government – not to mention public – review.
Measuring health care organizations against their peers is “important for quality improvement,” says Jeanie Lacroix, manager of performance improvement and capacity building at the Canadian Institute for Health Information (CIHI). “If you don’t know how others are doing, you can’t get a sense of where you’re at,” she explains. (It’s worth noting that while CIHI is currently developing a national standardized patient survey and will begin collecting data this spring, the organization isn’t yet working toward a national staff satisfaction survey.)
Standardized and reported tools can also aid governments and the public in identifying widespread issues that require national or provincial leadership. In Alberta, after a majority of staff across the province said they lacked training opportunities in the province’s 2010 staff survey, the government put funding towards more employee development programs. Training is now seen as an “area of strength” in the staff surveys, Armstrong explains. Without a standardized tool, Ontario, meanwhile, misses out on opportunities to shape policy based on staff satisfaction survey responses.
Of course, whether a survey is standardized or locally driven, it can give healthcare managers a false sense of consultation. The survey itself is not enough, says Ferguson-Paré; it’s simply one barometer. Healthcare managers still need to provide staff formal and informal opportunities to voice any concerns.
The Ottawa Hospital encourages staff feedback through their ‘It’s safe to speak up’ campaign. The campaign calls on staff to voice, in all meetings and forums, “if there’s anything bugging them, or if there is any place for improvement,” says Légaré. At UHN, Ferguson-Paré says, “I went to every unit, every department, and listened.”
After all, she explains, “staff know how to do the best thing for patients and if you invite them to be part of the solution, they can be and will be.”