Affinity & Pareto Chart Analysis at Herzog Memorial Hospital
The one outlier from the HCAHPS report was “The area around my room was quiet at night,” which was 14 points below the Colorado average.
Do the patient comments support or refute that score?
Overall there were only 16 out of 104, or 15%, of comments that were positive in the room category. These comments do not in itself refute or support the room is quiet at night; however, it does identify patient rooms a significant problem according to the aggregation of patient comments. Only 1 of the 16 comments stated in any way that the room was quiet. These represent less than 1% of overall comments. Out of the dissatisfied comments, 41% of feedback related to unacceptable noise levels. The second most common theme of complaint from the dissatisfied comments related to issues with other patients and roommates at 23% percent, and temperature of the room at 21%. Percentages are not mutually exclusive from one another and can incorporate multiple common themes of dissatisfaction. From this, we can conclude that the data do not refute the HCAHPS score, and that noise level is a significant factor in patient dissatisfaction.
Continuing, 29 of the 75 negative comments, or almost 39% used the words noise, noisy, or loud to describe the room. In the analysis, 44% of the comments complained about the room. The majority of these comments criticized the room being too loud or complaining about the noise outside. Of the 33 complaints about the rooms being too loud, 40% (13/33) specifically complained about the room being loud at night and being unable to sleep. These came from a variety of sources including but not limited to loud roommates (including the patient TV visitors), loud nurses, loud patients in other rooms, noise in the hallways at the nurses’ station, and noise from other patients and visitors in the halls and other rooms. Based on these facts, 41% of the negative comments were general complaints related to noise, and 40% of these were complaints directly relating to too much noise at night. Further analysis of these patient comments does support HCAHPS scores identifying noise at night as a problem area or area of opportunity.
Affinity Ideas List:
- Patients have a higher-level expectation of privacy
- The expectation of a low level of noise while in care
- Standardize room turnover process
- Comfort improves patient satisfaction
- Proper room cleanliness
- Too much noise
- Outdated facilities
- Noisy environment
- The temperature is uncomfortable for patients
- Problems with roommates
- Bathroom issues
- Properly ensuring that we dispose of the sheet when necessary
- Rooms are not comfortable for visitors
- We take too long to get things fixed in facilities
- Should group patients by acuteness level
- Employees are too noisy in the night shift
- Single patient rooms
- Is our staff noisy
- Proper Nurse operating procedures
- Do we have staffing issues?
Affinity Ideas & Categorization
Pareto Chart from the results of the affinity diagram
From the patient comments, what items (if any) need immediate attention?
Based on patient comments and analysis completed in the answers above, several areas require immediate attention. These are in the areas of noise levels, patient comfort, privacy, and nuisance stemming from patients, staff conduct, cleanliness, and facility concerns. Noise level, comfort, and privacy represent significant areas that have the most substantial impact on patient satisfaction.
In addressing these primary areas of concern, the following recommendations should be implemented immediately:
- Noise – Having identified that noise levels come from multiple sources, reduction of noise from sources that can be quickly addressed, such as the nurse station, care for patients in rooms with multiple occupants, and hallway noise should be controlled and reduced as much as possible.
- Temperature Control – Given that low temperatures hamper bacterial and viral growth, blankets should be readily available to patients to address complaints about low temperatures.
In addressing areas that were not of primary concern but could significantly impact both the reputation of the hospital and its image to patients, the following can be addressed with relative ease:
- Water Quality– At the bare minimum, un-yellowed, clean drinking water should be available to patients regardless of the potency of water with heavy iron content
- Cleanliness– More attention to the cleanliness of rooms and room turnover is needed. While the issue with the hospital’s water supply remains ongoing and challenging to address without an overhaul of the well, quickly eliminated health and cleanliness issues such as stained sheets, dusty rooms or dirty facilities should be attended to immediately.
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