John P. Moriarty, MD

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation

The United States spends more money per capita on healthcare than any other industrialized nation,1 yet patients are the least satisfied with their care.2 Patient satisfaction is associated in both cross‐sectional3 and longitudinal studies4 with improved physical and mental health outcomes. Conversely, dissatisfaction with care hampers future medical interactions, prevents sharing of information, and impairs the building of trust.5 The increasing recognition that a patient's experience of care affects patient outcomes has furthered efforts to evaluate satisfaction with care.6, 7

However, patient satisfaction is challenging to define and understand. Even the definition of satisfaction is ambiguous, for to satisfy can mean both to make happy and the lesser, to be adequate. To dissatisfy is to displease or disappoint, but dissatisfaction is not the opposite of satisfaction: qualitative studies give little if any indication that patients evaluate satisfaction on a continuum ranging from dissatisfied at one end to very satisfied at the other.8 Instead, it appears that satisfaction and dissatisfaction are different constructs, such that patients may simultaneously be both satisfied and dissatisfied.9, 10 Patients often express overall satisfaction with a service or encounter while also reporting specific criticisms about its shortcomings.11, 12 Alternatively, consumers may be generally satisfied unless something unpleasant or improper happens.13 Thus, dissatisfaction and satisfaction may require different methods of measurement.

The most common model for measuring patient satisfaction is a quantitative survey of patients' experiences in specific predetermined domains. Of 54 hospital satisfaction surveys in common use, only 11 included patient input in their development,14 casting doubt on the relevance of these attributes to patients' priorities of care. Since it is well recognized that patient expectations influence satisfaction,8, 13, 15 it is important to identify patient expectations and priorities up front. However, these have not been clearly established. Furthermore, focusing purely on satisfaction with particular domains of care may miss the separate but illuminating construct of patient dissatisfaction.

In this study we therefore aim to understand patient dissatisfaction with hospitalization more fully as a means of elucidating implicit expectations for hospital care. Using qualitative techniques, we analyzed a large volume of patient responses to a single open‐ended study question to identify determinants and patterns of patient dissatisfaction.

Methods

Results

A total of 976 surveys was randomly selected from 9,764 postdischarge phone interviews completed between July 1, 2007 and June 30, 2008. A total of 56.3% of patients was female. Nearly half the patients were discharged from medical units (Table 1). Of the 976 patients, 439 (45.0%) gave at least one suggestion for improvement, yielding a total of 579 suggestions. Patients also offered numerous positive comments about their care, but these comments were not included in the analysis.

Through qualitative analysis, we assigned suggestions for improvement to six major categories of dissatisfaction: 1) ineptitude, 2) disrespect, 3) prolonged waits, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. We considered the inverse of these problems to represent six implicit expectations of good hospital care: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities (Table 2). The number of patient suggestions related to each domain is detailed in Table 3.

Discussion

We analyzed 439 patient suggestions for improving hospital care and found that dissatisfaction resulted from six categories of negative experiences: 1) ineptitude, 2) disrespect, 3) prolonged wait times, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. These domains represented a corresponding set of implicit patient expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities. Each of these categories suggests avenues by which both the assessment and provision of hospital care can be made more patient‐centered.

The most widely used patient satisfaction survey in use in the United States today is the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS), which includes eight domains: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.17 The dissatisfaction domains found in this study closely overlap the HCAHPS satisfaction domains, but with a few key differences.

First, dissatisfaction with ineptitude in our study encompassed concerns over adverse events and near misses, in addition to the cleanliness of the environment. Other research has shown that dissatisfaction with hospitalization can be predicted by the number of reported problems18 and the perception of receiving incorrect treatment.19 While elaborate methods have been devised to assess and compare the hospital quality and safety, patient satisfaction surveys including the HCAHPS survey often fail to ask patients directly about their perceptions of safety. In fact, this study and others20, 21 show that patients are able to recognize adverse events during hospitalization. Patient report may be a useful adjunct to other methods of adverse event case finding and outcomes reporting.

Second, while HCAHPS and others identify warmth, courtesy, concern, and respect as dimensions of patient‐centered care,14, 17, 22, 23 the ability of quantitative satisfaction surveys to capture the experience of disrespectful treatment may be limited, especially during hospitalization. Most respondents who commented on feeling disrespected identified only a single encounter, which can be masked by otherwise satisfying interactions with numerous care providers. Directly asking patients whether any experience during hospitalization caused them to feel disrespected, and allowing room for explanation, might more efficiently identify problem areas. This is particularly important because even one episode of disrespectful treatment, particularly when perceived to be racially motivated, increases the likelihood of not following a doctor's advice or putting off care.24

Third, HCAHPS emphasizes two aspects of communication: that between patients and doctors, and that between patients and nurses. Our patients confirmed that these are important, but they also noted a third dimension of communication contributing to dissatisfaction: provider‐provider communication. Communication and coordination failures among providers are key contributors to adverse events or near misses,2528 but their influence on patient satisfaction has not been widely assessed. Furthermore, patient input is rarely utilized to identify poor interprovider communication. Our study suggests that, just as patients can identify adverse events, they are also able to recognize poor provider‐provider communication.

Patients' reports of dissatisfying events also highlight areas in which small changes in hospital practice might greatly improve the patient experience. For instance, concerns over environment, food, sleep, hygiene, and pain appeared to be representative of a broader dissatisfaction with loss of autonomy and control. Hospitalized patients are often obliged to room with strangers, are subject to noise and interruptions, and cede control of their medication management at a time when they are feeling particularly vulnerable. The importance of this lack of autonomy to patients suggests a variety of small interventions that could improve satisfaction, such as individual control of noise and temperature, a visible commitment to a quiet hospital environment, and minimized interruptions and sleep disturbance.2932 Single‐occupancy hospital rooms have been associated with lower rates of nosocomial infection, medication errors, and patient stress, as well as increased privacy, rest, visitor involvement, and doctor‐patient communication.33, 34 The most sophisticated intervention, acuity‐adaptable private hospital rooms, allows hospitals to maintain patients in the same private hospital room during an entire admission, regardless of changes to level of acuity.35

In‐depth analysis of suggestions for improvement, as gathered by telephone surveys of recently discharged patients, was a particularly well‐suited approach to identifying explicit expectations for care that were violated by dissatisfying incidents. When allowed to express dissatisfaction in terms of suggestions for improvement, patients talked freely about specific dissatisfying experiences. Using telephone interviews allowed a large volume of patient responses to be included, unlike smaller focus groups. Our study was oral and did not rely on the literacy level of patients. Additionally, the open‐ended nature of questioning avoided some of the usual pitfalls of satisfaction surveys. We did not rely on predetermined satisfaction categories or presume the inherent value of particular attributes of care. Nonetheless, our study does have important limitations.

Patient perceptions were not compared with chart data or clinician report. Caregivers were allowed to participate in lieu of patients, which may have reduced identification of some dissatisfying events. Likewise, patients discharged to nursing homes or who were not English or Spanish speaking were excluded and may have had different dissatisfying experiences. Interviews were brief and dissatisfying events were not explored in detail. Although nearly half of respondents reported dissatisfying events, some patients may have been reluctant to criticize their care directly to a hospital representative. Finally, patients generally confined their comments to one or two dissatisfying events, even though there may have been others. We therefore cannot draw any conclusions about the relative frequency of dissatisfying events by domain.

Conclusions

All hospitalized patients bring expectations for their hospital experience. While specific expectations vary between patients, expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities were found in this study to encompass core expectations for hospitalization. It may be useful to ensure that postdischarge surveys explicitly address these expectations. Efforts to address and manage these core expectations of hospital care may help to reduce patient dissatisfaction with hospitalization and improve the delivery and quality of hospital care.

The United States spends more money per capita on healthcare than any other industrialized nation,1 yet patients are the least satisfied with their care.2 Patient satisfaction is associated in both cross‐sectional3 and longitudinal studies4 with improved physical and mental health outcomes. Conversely, dissatisfaction with care hampers future medical interactions, prevents sharing of information, and impairs the building of trust.5 The increasing recognition that a patient's experience of care affects patient outcomes has furthered efforts to evaluate satisfaction with care.6, 7

However, patient satisfaction is challenging to define and understand. Even the definition of satisfaction is ambiguous, for to satisfy can mean both to make happy and the lesser, to be adequate. To dissatisfy is to displease or disappoint, but dissatisfaction is not the opposite of satisfaction: qualitative studies give little if any indication that patients evaluate satisfaction on a continuum ranging from dissatisfied at one end to very satisfied at the other.8 Instead, it appears that satisfaction and dissatisfaction are different constructs, such that patients may simultaneously be both satisfied and dissatisfied.9, 10 Patients often express overall satisfaction with a service or encounter while also reporting specific criticisms about its shortcomings.11, 12 Alternatively, consumers may be generally satisfied unless something unpleasant or improper happens.13 Thus, dissatisfaction and satisfaction may require different methods of measurement.

The most common model for measuring patient satisfaction is a quantitative survey of patients' experiences in specific predetermined domains. Of 54 hospital satisfaction surveys in common use, only 11 included patient input in their development,14 casting doubt on the relevance of these attributes to patients' priorities of care. Since it is well recognized that patient expectations influence satisfaction,8, 13, 15 it is important to identify patient expectations and priorities up front. However, these have not been clearly established. Furthermore, focusing purely on satisfaction with particular domains of care may miss the separate but illuminating construct of patient dissatisfaction.

In this study we therefore aim to understand patient dissatisfaction with hospitalization more fully as a means of elucidating implicit expectations for hospital care. Using qualitative techniques, we analyzed a large volume of patient responses to a single open‐ended study question to identify determinants and patterns of patient dissatisfaction.

Methods

Results

A total of 976 surveys was randomly selected from 9,764 postdischarge phone interviews completed between July 1, 2007 and June 30, 2008. A total of 56.3% of patients was female. Nearly half the patients were discharged from medical units (Table 1). Of the 976 patients, 439 (45.0%) gave at least one suggestion for improvement, yielding a total of 579 suggestions. Patients also offered numerous positive comments about their care, but these comments were not included in the analysis.

Through qualitative analysis, we assigned suggestions for improvement to six major categories of dissatisfaction: 1) ineptitude, 2) disrespect, 3) prolonged waits, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. We considered the inverse of these problems to represent six implicit expectations of good hospital care: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities (Table 2). The number of patient suggestions related to each domain is detailed in Table 3.

Discussion

We analyzed 439 patient suggestions for improving hospital care and found that dissatisfaction resulted from six categories of negative experiences: 1) ineptitude, 2) disrespect, 3) prolonged wait times, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. These domains represented a corresponding set of implicit patient expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities. Each of these categories suggests avenues by which both the assessment and provision of hospital care can be made more patient‐centered.

The most widely used patient satisfaction survey in use in the United States today is the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS), which includes eight domains: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.17 The dissatisfaction domains found in this study closely overlap the HCAHPS satisfaction domains, but with a few key differences.

First, dissatisfaction with ineptitude in our study encompassed concerns over adverse events and near misses, in addition to the cleanliness of the environment. Other research has shown that dissatisfaction with hospitalization can be predicted by the number of reported problems18 and the perception of receiving incorrect treatment.19 While elaborate methods have been devised to assess and compare the hospital quality and safety, patient satisfaction surveys including the HCAHPS survey often fail to ask patients directly about their perceptions of safety. In fact, this study and others20, 21 show that patients are able to recognize adverse events during hospitalization. Patient report may be a useful adjunct to other methods of adverse event case finding and outcomes reporting.

Second, while HCAHPS and others identify warmth, courtesy, concern, and respect as dimensions of patient‐centered care,14, 17, 22, 23 the ability of quantitative satisfaction surveys to capture the experience of disrespectful treatment may be limited, especially during hospitalization. Most respondents who commented on feeling disrespected identified only a single encounter, which can be masked by otherwise satisfying interactions with numerous care providers. Directly asking patients whether any experience during hospitalization caused them to feel disrespected, and allowing room for explanation, might more efficiently identify problem areas. This is particularly important because even one episode of disrespectful treatment, particularly when perceived to be racially motivated, increases the likelihood of not following a doctor's advice or putting off care.24

Third, HCAHPS emphasizes two aspects of communication: that between patients and doctors, and that between patients and nurses. Our patients confirmed that these are important, but they also noted a third dimension of communication contributing to dissatisfaction: provider‐provider communication. Communication and coordination failures among providers are key contributors to adverse events or near misses,2528 but their influence on patient satisfaction has not been widely assessed. Furthermore, patient input is rarely utilized to identify poor interprovider communication. Our study suggests that, just as patients can identify adverse events, they are also able to recognize poor provider‐provider communication.

Patients' reports of dissatisfying events also highlight areas in which small changes in hospital practice might greatly improve the patient experience. For instance, concerns over environment, food, sleep, hygiene, and pain appeared to be representative of a broader dissatisfaction with loss of autonomy and control. Hospitalized patients are often obliged to room with strangers, are subject to noise and interruptions, and cede control of their medication management at a time when they are feeling particularly vulnerable. The importance of this lack of autonomy to patients suggests a variety of small interventions that could improve satisfaction, such as individual control of noise and temperature, a visible commitment to a quiet hospital environment, and minimized interruptions and sleep disturbance.2932 Single‐occupancy hospital rooms have been associated with lower rates of nosocomial infection, medication errors, and patient stress, as well as increased privacy, rest, visitor involvement, and doctor‐patient communication.33, 34 The most sophisticated intervention, acuity‐adaptable private hospital rooms, allows hospitals to maintain patients in the same private hospital room during an entire admission, regardless of changes to level of acuity.35

In‐depth analysis of suggestions for improvement, as gathered by telephone surveys of recently discharged patients, was a particularly well‐suited approach to identifying explicit expectations for care that were violated by dissatisfying incidents. When allowed to express dissatisfaction in terms of suggestions for improvement, patients talked freely about specific dissatisfying experiences. Using telephone interviews allowed a large volume of patient responses to be included, unlike smaller focus groups. Our study was oral and did not rely on the literacy level of patients. Additionally, the open‐ended nature of questioning avoided some of the usual pitfalls of satisfaction surveys. We did not rely on predetermined satisfaction categories or presume the inherent value of particular attributes of care. Nonetheless, our study does have important limitations.

Patient perceptions were not compared with chart data or clinician report. Caregivers were allowed to participate in lieu of patients, which may have reduced identification of some dissatisfying events. Likewise, patients discharged to nursing homes or who were not English or Spanish speaking were excluded and may have had different dissatisfying experiences. Interviews were brief and dissatisfying events were not explored in detail. Although nearly half of respondents reported dissatisfying events, some patients may have been reluctant to criticize their care directly to a hospital representative. Finally, patients generally confined their comments to one or two dissatisfying events, even though there may have been others. We therefore cannot draw any conclusions about the relative frequency of dissatisfying events by domain.

Conclusions

All hospitalized patients bring expectations for their hospital experience. While specific expectations vary between patients, expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities were found in this study to encompass core expectations for hospitalization. It may be useful to ensure that postdischarge surveys explicitly address these expectations. Efforts to address and manage these core expectations of hospital care may help to reduce patient dissatisfaction with hospitalization and improve the delivery and quality of hospital care.

The United States spends more money per capita on healthcare than any other industrialized nation,1 yet patients are the least satisfied with their care.2 Patient satisfaction is associated in both cross‐sectional3 and longitudinal studies4 with improved physical and mental health outcomes. Conversely, dissatisfaction with care hampers future medical interactions, prevents sharing of information, and impairs the building of trust.5 The increasing recognition that a patient's experience of care affects patient outcomes has furthered efforts to evaluate satisfaction with care.6, 7

However, patient satisfaction is challenging to define and understand. Even the definition of satisfaction is ambiguous, for to satisfy can mean both to make happy and the lesser, to be adequate. To dissatisfy is to displease or disappoint, but dissatisfaction is not the opposite of satisfaction: qualitative studies give little if any indication that patients evaluate satisfaction on a continuum ranging from dissatisfied at one end to very satisfied at the other.8 Instead, it appears that satisfaction and dissatisfaction are different constructs, such that patients may simultaneously be both satisfied and dissatisfied.9, 10 Patients often express overall satisfaction with a service or encounter while also reporting specific criticisms about its shortcomings.11, 12 Alternatively, consumers may be generally satisfied unless something unpleasant or improper happens.13 Thus, dissatisfaction and satisfaction may require different methods of measurement.

The most common model for measuring patient satisfaction is a quantitative survey of patients' experiences in specific predetermined domains. Of 54 hospital satisfaction surveys in common use, only 11 included patient input in their development,14 casting doubt on the relevance of these attributes to patients' priorities of care. Since it is well recognized that patient expectations influence satisfaction,8, 13, 15 it is important to identify patient expectations and priorities up front. However, these have not been clearly established. Furthermore, focusing purely on satisfaction with particular domains of care may miss the separate but illuminating construct of patient dissatisfaction.

In this study we therefore aim to understand patient dissatisfaction with hospitalization more fully as a means of elucidating implicit expectations for hospital care. Using qualitative techniques, we analyzed a large volume of patient responses to a single open‐ended study question to identify determinants and patterns of patient dissatisfaction.

Methods

Results

A total of 976 surveys was randomly selected from 9,764 postdischarge phone interviews completed between July 1, 2007 and June 30, 2008. A total of 56.3% of patients was female. Nearly half the patients were discharged from medical units (Table 1). Of the 976 patients, 439 (45.0%) gave at least one suggestion for improvement, yielding a total of 579 suggestions. Patients also offered numerous positive comments about their care, but these comments were not included in the analysis.

Through qualitative analysis, we assigned suggestions for improvement to six major categories of dissatisfaction: 1) ineptitude, 2) disrespect, 3) prolonged waits, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. We considered the inverse of these problems to represent six implicit expectations of good hospital care: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities (Table 2). The number of patient suggestions related to each domain is detailed in Table 3.

Discussion

We analyzed 439 patient suggestions for improving hospital care and found that dissatisfaction resulted from six categories of negative experiences: 1) ineptitude, 2) disrespect, 3) prolonged wait times, 4) ineffective communication, 5) lack of environmental control, and 6) substandard amenities. These domains represented a corresponding set of implicit patient expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities. Each of these categories suggests avenues by which both the assessment and provision of hospital care can be made more patient‐centered.

The most widely used patient satisfaction survey in use in the United States today is the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS), which includes eight domains: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.17 The dissatisfaction domains found in this study closely overlap the HCAHPS satisfaction domains, but with a few key differences.

First, dissatisfaction with ineptitude in our study encompassed concerns over adverse events and near misses, in addition to the cleanliness of the environment. Other research has shown that dissatisfaction with hospitalization can be predicted by the number of reported problems18 and the perception of receiving incorrect treatment.19 While elaborate methods have been devised to assess and compare the hospital quality and safety, patient satisfaction surveys including the HCAHPS survey often fail to ask patients directly about their perceptions of safety. In fact, this study and others20, 21 show that patients are able to recognize adverse events during hospitalization. Patient report may be a useful adjunct to other methods of adverse event case finding and outcomes reporting.

Second, while HCAHPS and others identify warmth, courtesy, concern, and respect as dimensions of patient‐centered care,14, 17, 22, 23 the ability of quantitative satisfaction surveys to capture the experience of disrespectful treatment may be limited, especially during hospitalization. Most respondents who commented on feeling disrespected identified only a single encounter, which can be masked by otherwise satisfying interactions with numerous care providers. Directly asking patients whether any experience during hospitalization caused them to feel disrespected, and allowing room for explanation, might more efficiently identify problem areas. This is particularly important because even one episode of disrespectful treatment, particularly when perceived to be racially motivated, increases the likelihood of not following a doctor's advice or putting off care.24

Third, HCAHPS emphasizes two aspects of communication: that between patients and doctors, and that between patients and nurses. Our patients confirmed that these are important, but they also noted a third dimension of communication contributing to dissatisfaction: provider‐provider communication. Communication and coordination failures among providers are key contributors to adverse events or near misses,2528 but their influence on patient satisfaction has not been widely assessed. Furthermore, patient input is rarely utilized to identify poor interprovider communication. Our study suggests that, just as patients can identify adverse events, they are also able to recognize poor provider‐provider communication.

Patients' reports of dissatisfying events also highlight areas in which small changes in hospital practice might greatly improve the patient experience. For instance, concerns over environment, food, sleep, hygiene, and pain appeared to be representative of a broader dissatisfaction with loss of autonomy and control. Hospitalized patients are often obliged to room with strangers, are subject to noise and interruptions, and cede control of their medication management at a time when they are feeling particularly vulnerable. The importance of this lack of autonomy to patients suggests a variety of small interventions that could improve satisfaction, such as individual control of noise and temperature, a visible commitment to a quiet hospital environment, and minimized interruptions and sleep disturbance.2932 Single‐occupancy hospital rooms have been associated with lower rates of nosocomial infection, medication errors, and patient stress, as well as increased privacy, rest, visitor involvement, and doctor‐patient communication.33, 34 The most sophisticated intervention, acuity‐adaptable private hospital rooms, allows hospitals to maintain patients in the same private hospital room during an entire admission, regardless of changes to level of acuity.35

In‐depth analysis of suggestions for improvement, as gathered by telephone surveys of recently discharged patients, was a particularly well‐suited approach to identifying explicit expectations for care that were violated by dissatisfying incidents. When allowed to express dissatisfaction in terms of suggestions for improvement, patients talked freely about specific dissatisfying experiences. Using telephone interviews allowed a large volume of patient responses to be included, unlike smaller focus groups. Our study was oral and did not rely on the literacy level of patients. Additionally, the open‐ended nature of questioning avoided some of the usual pitfalls of satisfaction surveys. We did not rely on predetermined satisfaction categories or presume the inherent value of particular attributes of care. Nonetheless, our study does have important limitations.

Patient perceptions were not compared with chart data or clinician report. Caregivers were allowed to participate in lieu of patients, which may have reduced identification of some dissatisfying events. Likewise, patients discharged to nursing homes or who were not English or Spanish speaking were excluded and may have had different dissatisfying experiences. Interviews were brief and dissatisfying events were not explored in detail. Although nearly half of respondents reported dissatisfying events, some patients may have been reluctant to criticize their care directly to a hospital representative. Finally, patients generally confined their comments to one or two dissatisfying events, even though there may have been others. We therefore cannot draw any conclusions about the relative frequency of dissatisfying events by domain.

Conclusions

All hospitalized patients bring expectations for their hospital experience. While specific expectations vary between patients, expectations for: 1) safety, 2) treatment with respect and dignity, 3) prompt and efficient care, 4) successful exchange of information, 5) environmental autonomy and control, and 6) high‐quality amenities were found in this study to encompass core expectations for hospitalization. It may be useful to ensure that postdischarge surveys explicitly address these expectations. Efforts to address and manage these core expectations of hospital care may help to reduce patient dissatisfaction with hospitalization and improve the delivery and quality of hospital care.