Health & Medical Health & Medicine Journal & Academic

Association of Hospital Quality Ratings With Adverse Events

´╗┐Association of Hospital Quality Ratings With Adverse Events

Abstract and Introduction


Objective. To understand how patient-reported quality is related to adverse events (AEs).

Design. Random sample telephone survey.

Setting. Sixteen acute care Massachusetts hospitals.

Participants. Two thousand and five hundred and eight-two of 4163 (62% response rate) eligible adult patients.

Main Outcome Measures. Patients hospitalized from 1 April 2003 to 1 October 2003 provided global quality ratings and whether they experienced AEs. Service recovery, defined as efforts by a service provider to return customers to a state of satisfaction after a lapse in service, was operationalized as high participation in one's care, timely discharge and disclosure of the circumstances of an AE.

Results. Of respondents, 82% rated the quality as high and 23% reported one or more AEs. Patients with no AEs gave higher quality ratings (85 vs. 77 or 62% for patients with 1 or 2+ AEs, respectively, P < 0.001). Patients were more likely to rate the quality high if they reported high participation (86 vs. 53%), or felt discharge timing was just right (85 vs. 64%); for those with AEs, ratings were higher among those reporting disclosure (82 vs. 66%) (all P < 0.01). In adjusted analyses, patients with AEs experiencing all three service recovery components rated their quality higher (86 vs. 68%, P < 0.01).

Conclusions. Patients with AEs rate the quality of care lower than others. However, patients with AEs who experienced 'service recovery' as we defined it rated their quality of care at levels similar to those who did not experience AEs. Hospitals seeking to improve quality ratings might consider efforts to ensure patient safety and to address AEs in a transparent and responsive way.


Although patient safety is a cornerstone of quality, the relationship between patient safety and patient experience of care is not well understood. Patient ratings of their hospital experience are increasingly common, and CMS now requires hospitals to provide quarterly reports of their Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) data ( Such evaluations can be useful to payers, regulators and patients who wish to gauge the quality of health care received from the patient's perspective.

Patient reports represent an important alternative to medical charts as a source of information about the frequency and type of safety events. Patients may be more willing than clinicians to report mishaps and harm, and also are more sensitive to underlying changes in their own symptoms and functional status. Only recently, investigators have begun to explore the utility of allowing patients to report directly on the occurrence of adverse events (AEs) and complications. Few data exist to indicate how patient-reported AEs relate to their perceptions of overall quality of care.

As a practical matter, if incident AEs take place, the response to them by hospital staff could have an important impact on patients' perceptions of the event and overall quality of care. In the business world, this is referred to as 'service recovery', defined as efforts by a service provider to return customers to a state of satisfaction after a service breakdown. For example, hospitals may promote disclosure of an event by a healthcare worker to the patient, or take special efforts to foster communication with providers and shared decision-making, or focus assiduously on discharge planning to ensure a smooth transition following hospitalization. It would be helpful to know whether such aspects of hospital care independently affect quality ratings and are sufficient to overcome the potential negative perceptions associated with an AE.

To better understand these issues, we surveyed patients discharged from acute care hospitals in Massachusetts about their experiences with AEs. In this analysis, we hypothesized first that patients' global measures of hospital quality were negatively affected by the occurrence of an AE, and secondly that hospitals' attention to the patient experience, including disclosure of AEs, fostering communication with providers, and ensuring timely discharge, would mitigate negative assessments of care following hospital-acquired AEs.

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