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Should hospital staff satisfaction survey results be public?

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.”

7 Comments
  • Maura MacPhee, Associate Professor UBC School of Nursing says:

    I support data openness and transparency. The NHS websites for their trusts/healthcare regions provide some excellent examples of how user-friendly data can be shared with the public. For example, take a look at the Gloucestershire website (http://www.2gether.nhs.uk/). At the bottom of the page is a link to its quality/safety report from the Care Quality Commission (CQC). The CQC is an indepdent regulator for healthcare and social care in England. Standardized, simple symbols and explanations are used by the CQC for every NHS trust site. Each trust site has a link to the CQC—so that the public can easily locate a quality/safety report card for any NHS trust. Public sharing of data has helped to rebuild trust in the NHS.
    I would also recommend the UK Patient Opinion website (https://www.patientopinion.org.uk/)–a site that shares patient/family stories and care provider comments. The site also tracks the number of positive changes that have resulted from public postings. In the NHS, a move towards more data transparency has increased healthcare accountability and the public’s belief in its healthcare system. In the NHS/England and in many US states, publicly posted data include: standardized staff satisfaction surveys, standardized patient satisfaction surveys, human resource data (e.g., staffing levels on units), and patient outcomes (e.g., falls with fractures). I believe that we should move towards standardized collection and public reporting of these data for benchmarking purposes—and to ensure public and employee trust in Canadian healthcare delivery.

  • Brian Orr says:

    Having been involved in championing, designing, overseeing and following up on employee surveys I am a strong advocate for the publicizing of the results within a healthcare organization including full disclosure to the Board. Given the complexity of the data and the critical need to have information about the culture and context in which a survey is undertaking, I am cautiously supportive of the sharing of the results with other peer healthcare organizations, government and to some extent with the share if high-level aggregate results with the public.

    The purpose of well designed employee surveys is to provide the healthcare management with data to assess the state of employee engagement, impact on various programs and initiatives, and understand the major concerns and opportunities for improvement from the perspective of those who work in the organization. It needs to be used as an organizational improvement tool.

    The challenge with mandated and standardized metrics is the degradation of the results to a point of information mediocrity.

    Perhaps the place to start is for the requirement for each healthcare organization to public report on its employee engagement practices, provide summary of the key findings, their follow-up action plans, and progress to improve employee engagement.

  • Elizabeth Rankin says:

    This article covers the issues all working in health care face. I would recommend that anyone working in the public hospital system at any level and beyond become familiar with the principles and practices that are required to accomplish “Smart Hospitals, Safe Patients,” a book written by Dr. Peter Pronovost MD, who along with his team set up an online course, “The Science of Patient Safety.”

    Without an understanding or the participation of each person who is employed in health care settings, patients are at risk and staff and management can’t fix the problems.

    The course that is offered through the Johns Hopkins joint schools of Medicine & Nursing in conjunction with The Armstrong Institute for Patient Safety is the best place to begin. The course uses a case study method and can be taken online and it runs in June through July for 5 weeks; it is free. It can also be done onsite at different times and locations over a week period at a cost to the individual.

    I can’t say enough good about this course. I’ve been retired from Nursing for years and it helps me all the time appraise, evaluate, make suggestions and prepares me or my family when I enter in the role of the patient.

    We are all at risk. Don’t wait until you find out the hard way. Be proactive and take the next course.

    If I were heading up any health related organization whether it was private or public I wouldn’t hire anyone until they took this course!

    Once you and others take this course, ensure your workplace has made the changes you need to see happen. Those that take the course will feel frustrated with system, well beyond the way they already feel it is. You get the tools you need to make it happen. You see how the problems occur, and how to fix what needs fixing. It isn’t rocket science.

    Those who balked at having to take the course became convinced it was the best course they’d taken!

    Best wishes in trying to overcome what obstacles you currently face.

    Respectfully,

    Elizabeth Rankin BScN

    • Gavin Fay says:

      I knew someone of your name who completed her nurse training at KCH, London in early 1965. Could this be you?

      Best Regards,

      Gavin

  • Wilmer Matthews says:

    Definitely !! Who better knows the system or organization’s merits, and short comings than front line staff. Forward thinking managers/CEOs recognize that these people as their most valuable resource, and actively solicit their ideas/opinions etc. on a continuing basis in a commitment to on-going improvement!

  • Judy Birdsell says:

    This is a very important conversation to be having! What would it take to have standardized patient AND staff surveys done and reported regularly? The loop does need to be closed though, in ensuring the results are attended to and actually influence actions. I strongly support any measures such as these that are valid, done regularly, reported in such a way as to be readily accessible by citizens (patients and staff) and in enough detail to enable action.. while working towards having them be helpful tools, and not tools to be used for punishment etc.

  • ELINOR CAPLAN says:

    In principle YES the surveys should be made public but first and at least sent to Health Quality Ontario. However, in my opinion, only the Hospital name should be known. I believe in Continuous Quality Improvement which requires that you eliminate ‘Blame & Shame’ Strategies. My concern is that there would be retaliation against the staff by management. %featured%We all believe that some hospitals ‘fudge’ quality & safety reporting now, so how accurate would the surveys be without auditing? This is really a tricky issue!%featured% Elinor Caplan

Authors

Joshua Tepper

Contributor

Joshua Tepper is a family physician and the President and Chief Executive Officer of North York General Hospital. He is also a member of the Healthy Debate editorial board.

Wendy Glauser

Contributor

Wendy is a freelance health and science journalist and a former staff reporter with Healthy Debate.

Debra Bournes

Contributor

Dr. Debra Bournes is the Chief Nursing Executive and Vice-President of Clinical Programs at The Ottawa Hospital.

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