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Seminars in Pediatric Surgery 

journal homepage: www.elsevier.com/locate/sempedsurg 

Importance of patient and family satisfaction in perioperative care 

Kristen A. Calabroa,b, Mehul V. Ravalc, David H. Rothsteina,b,n 
a Department of Pediatric Surgery, John R. Oishei Children’s Hospital, Buffalo, NY, USA b Department of Surgery, University at 
Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA c Department of Pediatric Surgery, Children’s 
Healthcare of Atlanta, and Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA 
article info 
Keywords: Patient satisfaction Surveys Communication Multidisciplinary care 
https://doi.org/10.1053/j.sempedsurg.2018.02.009 1055-8586/& 2018 Elsevier Inc. All rights reserved. 
As  healthcare  systems  increasingly  shift  focus  toward  providing  high-quality  and  high-value  care  to  patients,  there  has  been  a 
simultaneous  growth  in  assessing  the  patient's  experience  through  patient-  reported  outcomes.  Along  with  well-known  patient 
reported  outcomes  such  as  health-related  quality  of life and current health state, patient satisfaction can be a valuable assessment 
of  quality.  Patient  and  family  satisfaction  measures  not  only  affect  a  patient’s  clinical  course  and  influence  overall  patient 
compliance,  but  are  increasingly  used  to  gauge  physician  performance  and  guide  reimbursement.  The  paucity  of  standardized 
measures  and  the  subjective  nature  of  patient  and  family  satisfaction  impairs  a  surgeon’s ability to internalize this feedback and 
institute  actions  to  optimize  clinical  care.  This  review  seeks  to  identify  areas  to improve patient and family satisfaction with the 
perioperative experience. 
& 2018 Elsevier Inc. All rights reserved. 
Most  contemporary  attention  on  improving  healthcare  quality  and  value  has  been  on  domains  of  care  influenced  by  care 
providers  and  healthcare  systems.  Outcomes,  specifically  for  sur-  gery,  have  traditionally  focused  on  mortality,  complications, 
and  easily  measurable  metrics  such  as  length  of  hospitalization  or  readmission.  The  patient  perspective  has  too  often  been 
missing  from  these  efforts  and now, more than ever, the importance of the patient voice is being recognized. The basic principles 
of  patient-  centered  care  include:  access  to  care, continuity and transition, involvement of family and friends, emotional support, 
physical  comfort,  information  and  education,  coordination  and  integration  of  care,  and  respect  for  patients’  preferences.1 
Essential  to  these  principles  is  the  healthcare  system  and care providers’ willingness to participate in the process and collaborate 
with  patients  and  major  stakeholders  in  their  care.  For  surgery,  a  variety  of  patient-  reported  outcomes  have  been  identified 
including  satisfaction,  quality  of  life,  disability,  mood  disorder,  and  pain.2  These  domains  are  often  overlapping,  highly 
subjective,  and  each  have  measure-  ment  tools  in  various  stages  of development and validation. For the purposes of this review, 
we will focus on patient and family satisfaction. 
Patient  and  family  satisfaction  are  essential  quality  measures  that  can  inform  improvements  in  the  perioperative experience. 
Patient  satisfaction  has  become  an  important  metric  for  hospital  and  physician  performance  and  is  increasingly  associated with 
reimbursement.3  Satisfaction  not  only  affects  a  patient’s  clinical  course,  but  can  also  have  an  impact on adherence to treatment 
plans.  Poor  patient  satisfaction  increases  the  likelihood  of  medical  malpractice  claims  after  unfavorable  outcomes.4 Patient and 
care-  giver  satisfaction  involves  understanding  a  complex  and  dynamic  relationship  between  healthcare  providers  and  patients 
that  includes  elements  such  as  expectations,  perceptions  regarding  quality  of  care,  and  two-way  communication.  Professional 
organ-  izations  and  societies  including  the  American  Academy  of  Pedia-  trics  (AAP)  and  the  Institute  of Medicine (IOM) have 
prioritized  improved  patient  outcomes  through  patient-centered care. Cus- tomizing care according to patient needs and values is 
essential  to  achieving  this  goal.5  The  struggle  to  identify  factors  that  influence  the  overall  patient  experience  is  even  more 
significant  in  the setting of specialty practices.6 Effective evaluation, utilization and application of patient and family satisfaction 
surveys can improve the overall patient experience. Nonetheless, despite conceptual simplicity, altering and improving care based 
on such subjective measures has proven to be challenging. 
Unique challenges in the pediatric patient population 
n Correspondence to: Pediatric Surgery, 1001 Main St, 3rd Floor, Buffalo, NY 14203, USA. 
There are unique challenges in the assessment of patient and 
E-mail address: drothstein@kaleidahealth.org (D.H. Rothstein). 
family satisfaction for the pediatric perioperative patient. First, 
Seminars in Pediatric Surgery 27 (2018) 114–120 
patient  experience  must  be  measured  from  the  perspective  of  both  the  child  and  the  adult  care  provider.5  Often,  the  fear  and 
anxiety  pediatric  patients  experience  can  be  amplified  by  their  caregiver’s  anxiety.7  Second,  information  should  be 
communicated  to  the  family  unit  at  multiples  levels  to  both  obtain  informed  consent  from  adult  care  providers  and 
age-appropriate  assent  whenever  possible.  This  highlights  the  importance  of  assessing  baseline  health  literacy  of  adult  care 
Interestingly,  caregiver  dissatisfaction  with  pediatric  surgical  experiences  was  related  to  higher  caregiver  education  levels.5 
Other  factors  associated  with  lower  caregiver  satisfaction  included  longer  surgical  procedures,  surgical  complications,  and 
caregivers  feeling  overwhelmed.5  Caregiver  apprehension,  in  turn,  interferes  with  assimilation  of  data.  Causes  for 
misunderstanding  are  oral  communication  of information, use of technical vocabulary, and level of education. It is estimated that 
40-80%  of  spoken  informa-  tion  provided  by  physicians  is  immediately  forgotten.9  Incomplete  or  incorrect  information 
transmission  may  occur  when  only one caregiver is present during consultation. The anxiety caregivers feel as a result of hearing 
that their child needs to undergo surgery often leads to distraction and unanswered or forgotten questions.9 
Patient and family satisfaction measures 
Despite  the  importance  of  assessing  patient  satisfaction,  there  is  no  standardized  process  or  widely  accepted  method  to 
measure  this  outcome.6  One  of  the  most  frequently  used  methods  to  obtain  patient  and  family  satisfaction  data  is  a 
patient-reported  outcome  survey.  Herein,  patients  (or  caregivers)  report  their  own  percep-  tions  of  the  impact  of  disease  and 
treatment  as  clinical  end-  points.10  Patient  satisfaction  surveys  are  usually  focused  on  the  immediate  post-operative  and 
post-discharge  interval,  but  longer-  term  data  are  lacking  and  may  be  insightful.  These  surveys  are  doubly  complex  due  to  the 
aforementioned need to assess out- comes from both the child’s and the caregiver’s perspective. 
The  majority  of  information  regarding  patient  satisfaction  is  currently  obtained  from  the  nationally  standardized  and 
publically  reported  Consumer  Assessment  of  Healthcare  Providers  and  Sys-  tems  (CAHPS)  Hospital  Survey.  This  Centers  for 
Medicare  and  Medicaid  Services  (CMS)  endorsed tool is the first to allow valid comparisons to be made across hospitals locally, 
regionally  and  nationally.11  Despite  development of alternative surveys to garner patient satisfaction feedback, CMS regulations 
over  the  types  of surveys that hospitals are allowed to administer render the implementation of new surveys difficult. Thus, many 
healthcare  systems  have  turned  to  less  conventional  methods  to  collect  information  using  commercially-available  internet  tools 
such  as  SurveyMonkey  (SurveyMonkey  Inc.,  San  Mateo,  California,  USA).  Currently  available  satisfaction  surveys  are  not 
specific  to  peri-  operative  patients.  Furthermore,  many  of  the  existing  surveys  are  intended  for  patients  who  were  hospitalized 
rather than treated as outpatients. 
The  CAHPS  Hospital  Survey  focuses  on  quality  assessment  relating  to  communication  between  physicians,  other  care  pro- 
viders,  and  patients.  This  survey  can  be  completed  via  mail,  telephone,  mail  with  telephone  follow-up,  or  interactive  voice 
recognition  prompts.  Beginning  in  2002,  CMS  partnered  with  the  Agency  for  Healthcare  Research  and  Quality  (AHRQ)  to 
develop  and  test  the  CAHPS  survey.11  In  2006,  the  survey  was  implemented  with  the  first  public reporting of results in March 
In  October 2014 Boston Children’s Hospital created the pedia- tric CAHPS survey.12 This survey asks caregivers to report on 
both  their  child’s  inpatient  experience  and  their  own  experience  with  their  child’s  inpatient  stay.  The  survey  was  designed  to 
measure the patient-centeredness of hospital care for patients less than 17 
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 115 
years  old.  Questions  focus  on  communication,  hospital  environ-  ment,  appropriateness  of  care,  pain  management,  and  other 
domains  that  caregivers  viewed  as  important  aspects  of  their  child’s  care.  The  pediatric  CAHPS  survey  has  62  items,  takes 
approximately  15  minutes  to  complete,  and  feedback  is  organized  into  five  specific  areas:  communication  with  caregivers, 
commu-  nication  with  children,  attention  to  safety  and  comfort,  hospital  environment,  and  global  rating.  The  survey  is 
administered  via  phone  or  mail.  Due  to  the  duration  and  the  inability  to reach all patients, response rates tend to be low, and the 
pediatric CAHPS does not take capture patients who have same day surgery. 
Press Ganey patient experience surveys combine the required CAHPS questions with scientifically-developed patient-centered 
questions  to  provide  the  most  comprehensive  view  of  the  overall  patient  experience.13  While  the  CAHPS  survey  measures 
patient  experience (how often a service was provided), additional Press Ganey questions reveal important qualitative details (how 
well  a  service  was  provided),  enabling  for  a  more  balanced  perspective  of  patient  care  within  your  organization.13  There  are 
other  propri-  etary  survey  tools  available  in  various  stages  of  development  and  validation  to address outpatient experiences and 
various specific aspects of care. 
Further  standardized  measurement  tools  for  patient  experience and satisfaction are lacking.5 Such tools could standardize the 
currently  heterogeneous  data  collected,  assist  in  research  and  quality  improvement  efforts,  and  allow  findings  to  be  more  valid 
and generalizable.5 
Patient satisfaction and pediatric surgery 
The  IOM has defined patient-centered care as care that is respectful of and responsive to individual patient preferences, needs, 
and  values  while  ensuring  patient  values  guide  clinical  decisions.14  The  AAP  recommends  that  patient-  and  family-cen-  tered 
care  be  incorporated  into  all  aspects  of  children’s  surgical  perioperative  experiences.15  This  patient-centered focus has become 
essential  to  the  streamlining  everyday  operative  care  plan  by  decreasing  patient  confusion  and  increasing  communication 
between  care  providers  and  between  patients  and  care  providers.  While  paramount,  specific  techniques  to  improve 
communication  do  not  exist.  Many  hospitals  have  developed  competency  curricula  focused  on improving communication skills 
such as active listen- ing, responding to patients' feelings with empathy and respect, and negotiation.16 
There  are  a  multitude  of  additional,  non-clinical  factors,  such  as  staff  friendliness  and  facilities/amenities  that  can influence 
the  overall  patient  experience.6  Care  providers  can  further  build  the  patient-physician  relationship  by  showing  empathy,  by 
having  direct  eye  contact,  appropriate  facial  expressions,  engaging  body  language,  as  well  as  appropriate  touch.17  Actively 
listening,  engag-  ing  body  language  and  appropriate  touch  can  all  be  further  improved  through  training  sessions  and  easily 
implemented  in  a  pediatric  surgery  clinic.6  Overall  satisfaction  is  correlated  with  the  child’s impression of the nurse as friendly 
and  the  nurse  and  doctor as transmitting serenity.18 Pooled results demonstrate associations among satisfaction and continuity of 
care,  provider  interpersonal  behavior, the care team comforting the child, explaining what is going on in the surgical process, and 
answering  questions.5  These  concepts  are  often  taught in medical school but require further attention as physicians travel deeper 
into their practices. 
Improvements  upon  patient  and  family  satisfaction  can  be  made  with  each  patient-family-provider  interaction.6  It  is  not 
uncommon for a lack of provider-patient communication to leave patients feeling unclear, anxious, and uncertain. Patients may 
question  their  provider’s  decision-making  ability.  Due  to  the  complexity  of  diseases  and  disorders  in  a  pediatric  population, 
patients  encounter  a variety of specialists and meet multiple members of the care team during each visit.6 A unified care plan can 
instill  a  confidence  in  the  solidarity  of  care  team  and  conveys  clear  provider  to  provider  communication.  Additional  improve- 
ments  to  patient/family  satisfaction  can  occur  when  effectively  engaging  the  patients  and their families in discussions and plans 
pertaining  to  goals  of  care  (see  Heiss  and  Raval’s  comments in their discussion of patient engagement in this issues of Seminars 
in Pediatric Surgery). 
Significance of patient and family satisfaction 
Unsolicited  patient  observations  of  surgeons  have  been  shown  to  be  associated  with  increased  risk  of  surgical  and  medical 
complications.  Cooper  et  al.  used  data  from  7 academic medical centers participating in a patient advocacy reporting system and 
assessed  surgical  outcomes  in  the  National  Surgical  Quality  Improvement  Program.19  They  found  that  the  adjusted  rate  of 
complications  was  13.9%  higher  for  patients  whose  surgeon  was  in  the  highest  quartile  of  unsolicited  patient  observations 
compared  with  patients  whose  surgeon  was  in  the  lowest  quartile.  They  concluded  that  efforts  to  promote patient safety should 
continue to focus on surgeons’ ability to communicate respectfully and effectively with patients and other medical professionals. 
Patient  and  family  satisfaction  can  also  influence  a  patient’s  clinical  course  by  impacting  adherence  to  treatment  plans. 
Improved  patient  care  is  the  most  important  benefit  of  optimizing patient and family satisfaction, but there are additional factors 
that  physicians  must  also  consider. Low satisfaction has been associ- ated with the likelihood of medical malpractice claims after 
unfavorable  outcomes.4  Negative  experiences  may  affect  referral  patterns,  community  and  hospital  rankings, and possibly even 
reimbursement.20  Both federal government and health insurance plans are utilizing quality of care as a central measure for which 
hospitals  are  paid,  through  the  value-based  purchasing  program.21  In  October  2012,  the  CMS  began  withholding  hospitals’ 
Medicare  reimbursement  based  on  their  quality  performance.  Thirty  percent  of  the  decision  was based on how well the hospital 
scored on the CAHPS survey.22 
We  have  summarized  recommendations  for  improving  patient  and  parent satisfaction in the accompanying Table 1. They are 
divided  into  Communication,  Informed  Consent,  Perioperative  Obstacles,  Outpatients,  Inpatients  and Multidisciplinary Rounds, 
Physician Training, and Discharge. 
Although  the  perioperative  experience  should  be  viewed  as  a  complete  experience,  it  is  important  to  focus  on  the  factors 
affecting  each  of  the  phases  of  care:  preoperative,  intraoperative,  and  postoperative.  The major thrust of communication centers 
on  creating  therapeutic  alliances  between  patient/family  and  the  care  provider.  Communication  can  take  many  forms,  and 
reinforcing  oral  communication  that  is most common in the office setting with written and even internet/video-based formats can 
be quite helpful. 
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 116 
Informed consent 
The  informed  consent  process  is  frequently  lacking  in  detail,  discussion  of  alternative treatments, and in-patient comprehen- 
sion. Checklists and iterative conversations can be helpful. 
Perioperative family obstacles 
Parents  can  feel  helpless  while  their  child  is  away from them in an operating room or procedure suite. Providing comfortable 
physical space and frequent updates can help alleviate some of these feelings. 
Outpatient surgical patients 
Clinical  practice  guidelines  and  the  provision  of  web-based  and  written  information  can  be  helpful  to  families,  as  are  post- 
operative phone calls early in the recovery time period. 
Surgical inpatients and multidisciplinary, family-centered rounds, young physician training 
Multidisciplinary,  family-centered  rounds  can  be  very  helpful  for  inpatients and families, as well as care teams. They engage 
families,  reduce  communication  errors,  and  allow  for  real-time  teaching  and  problem-solving.  An  additional  benefit  may  be 
found in the training of residents, who might be observed during their interaction with care teams and patients and families. 
Streamlining  the  discharge  process  through  encouraging  patient/family  engagement,  point-of-service  nursing  autonomy  and 
provision  of  written  communication  has  multiple  benefits,  including  reducing  unnecessary  bed  utilization,  allowing  families  to 
return  to  their  usual  home  environments,  and  providing  the appearance of organization. Discharge checklists have proven useful 
to simplify the process (Fig. 1).23 
Future directions 
Application  of  integrated  technology  to  improve  perioperative  satisfaction  is  being  more  frequently  utilized.  One  center  set 
out  to  improve  intraoperative  communication  using  paddle  pagers,  dig-  ital  pagers, and nursing liaisons.3 Families were given a 
pager  at  check  in,  and  within  the  electronic  medical  record,  a  system  was  created  so  four  standard  messages  or  one  free  text 
option,  limited  to  eighty  characters for clarity, could be sent to the pagers. Update reminders appeared for the circulating nurse at 
timed  intervals  at  which  point  the  nurse  could  select  an  appropriate  standardized  or  custom  message.  Six  months  after  initial 
implementation,  surveys  were  administered  to  patient’s  families,  nurses,  and  surgeons  to  assess  the  effects  of  the  new 
intraoperative  paging  system.  Surveys  noted  an  overall  trend  that  the  pager  was  easy  to  use,  family  members  felt  comfortable 
leaving  the  waiting  room  without  concern  of  not  receiving  updates,  and  all  reported  receiving  information  they  wanted  during 
surgery.  Press-Ganey  survey scores validated the findings. Eighty-one percent of nurses sur- veyed responded to the survey, none 
of  whom  reported  difficulty reaching families. Ninety-six percent believed families were get- ting desired information and ninety 
percent  believed  the  paging  system  brought  value  to  their  patient’s  family  experience.  Many  believed  the  system  also  allowed 
them to stay within their work- space more often than before. Surgeons had a seventy-six percent 
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 117 
Table 1 Recommendations for improving patient and parent satisfaction. 
Recommendation Importance Implementation 
Communication Initiate communication early. Communication and trust are key foundations in building a 
successful physician-patient relationship, particularly prior to surgery.6 
Establish a basis for strong communication at the first visit. 
Data must be understood and integrated by the patient/ 
their parent despite anxiety.9 The benefits of strong communication between surgeons 
and their patients’ families reaches beyond anxiety reduction and improved patient satisfaction score.3 Be knowledgeable/share 
knowledge. Studies correlate patient’s trust with patient’s perception of 
physician communication, level of interpersonal treatment, and perception of physician knowledge.26 
Create a fluid dialogue between physician, patient/patient’s families in order to share information and unify all parties with 
vested interest. Shared knowledge enables formation of a unified 
understanding and a “therapeutic alliance” for making well informed medical decisions.3 In the operative setting, perception of 
the care team as 
knowledgeable and caring was correlated with higher satisfaction scores.5 Involve the patient and their parents in the 
treatment plan. 
The crux of the patient care experience is measured by the 
parents’ involvement in treatment as well as ultimate medical decision making.5 
Continue active communication, even during high-anxiety 
periods, that involved the patient and their parents. 
A healthy patient-physician relationship, indicated by a 
patient’s likelihood to recommend the care provider and patients’ confidence in the care provider, were major deciding factors in 
patient.6 Provide personalized preoperative leaflets. Personalized preoperative leaflets have improved 
comprehension-memorization, information quality, and parental satisfaction by reinforcing the feeling of receiving quality care, 
while significantly decreasing anxiety. 
Use a combination of verbal and written information. 
Written information should supplement spoken information 
and is no way a substitute for verbal information.9 

Get family and patient input in order to personalize to the 
patient’s specific needs. Preoperative literature proved to be most effective when it was created with the family’s and patient’s 
needs and goals in mind and is patient specific. Implement therapeutic play, video 
educational tools, and supplemental home materials. 
Evaluating the care experience of parents and children with 
such methods demonstrated a decreased anxiety in both children and parents and significantly higher patient satisfaction.5 
Utilize various methods in order to achieve higher 
Take time, answer all post-operative 
More likely to relieve some anxiety surrounding the surgical 
procedure and may even prevent many postoperative phone calls. 
Designate time for postoperative questions. 
Effective communication can also improve health outcomes 
including function and pain control.3 Manifest proper body language and 
Non-clinical factors, such as physician-patient relationship, staff friendliness, and environment of the practice, are particularly 
influential in determining the overall patient experience.6 
These skills can all be further improved through training 
sessions and can be easily implemented.6 
Build the patient-physician relationship by showing 
empathy, by having direct eye contact, appropriate facial expressions, engaging body language, as well as appropriate touch.17 
Overall satisfaction is correlated with the child’s impression 
of the nurse as friendly and the nurse and doctor as transmitting serenity.18 There are associations among satisfaction and 
continuity of 
care, provider interpersonal behavior, the care team comforting the child, explaining what is going on in the surgical process, and 
answering questions.5 
Informed Consent Utilize an informed consent checklist The informed consent process is suboptimal.27 These discussions should 
be agreed upon prior to providers 
discussing surgical procedures with patients. Inconsistencies during 
informed consent discussions are 
Resident education should include effectively initiating and 
properly obtaining informed consent. Each surgeon’s unique variation 
leads to a lack of consistent 
and standardized information being delivered making it difficult for patients to make an informed decision.27 After 
implementation of an informed consent checklist the overall average satisfaction score significantly increased for general 
Perioperative family obstacles Provide clean, quiet, comfortable Surgical 
Waiting Areas 
Surgical waiting areas are frequently criticized on Press- 
Ganey satisfaction surveys, with many families expressing dissatisfaction due to lack of comfort or overcrowding.3 
Assess waiting areas and renovate if necessary. 
Table 1 (continued ) 
Recommendation Importance Implementation 
These factors contribute to many families seeking out an alternative place to wait and therefore making them difficult to find after 
an operation. Have a reliable communication system for 
family updates during an operation. 

This system will additionally allow for family tracking after surgery Reliable perioperative family communication is crucial for 
completion. optimal patient satisfaction but is hindered by difficulty locating families.3 Have postoperative family discussions 
answer questions. 
Updates during the operation help calm anxieties and allow 
the family to feel connected to the surgery. 
Use of an intraoperative paging system. 
Answer all questions, utilize intraoperative photos or 
diagrams as able. 
Outpatient surgical patients Provide additional written postoperative 
Time spent addressing questions and concerns ultimately 
leads to improved patient satisfaction as well as better adherence to discussed treatment plans due to an increased understanding 
of the goal and the steps needed to reach that goal. 
Distribute postoperative information packets upon 
Reduces anxiety, increases understanding, and improves 
patient and family satisfaction. Make routine postoperative follow up 
telephone calls. 
Additional written postoperative information is an effective 
way to deliver accurate information allowing patients and family members to reference it should further questions arise. 
Postoperative telephone calls related to high satisfaction 
Physician or designated office staff to perform postoperative scores.5 
telephone call. 
Surgical in-patients and multidisciplinary, family-centered rounds Recommendation Importance Implementation Patient 
rounds should be family-centered. Family-centered rounds create a sense of common purpose, a 
sense of personal and collective power, active listening, shared responsibility for leadership, translucency to the problem-solving 
process, and a feeling of respect with a sense of collaboration and team spirit.28 
There should be collaboration between families and health 
care providers, and family to family networking and support should be facilitated.28 
The use of interdisciplinary teams helps improve patient care, 
communication, safety culture, and overall patient satisfaction6. 
Create ground rules for rounds to significantly decrease 
rounding time. 
Family-centered rounds were associated with higher parent satisfaction, consistent medical information and care plan discussion, 
with no additional burden to use of health services.29 Poor communication has been identified as a major 
contributor to adverse events and compromised patient outcomes.30 Multidisciplinary family centered rounds 
should be incorporated into the training aspect for future and young physicians. 
Multidisciplinary family-centered rounds are not only 
Attending physicians should make sure to include residents important to 
patient care, but are additionally significant in 
and students during multidisciplinary rounds and the training of our future 
surgeons and other care providers. 
constructively critique them so that they can improve The Accreditation 
Committee for Graduate Medical 
their skill set. Education includes among residency training core competencies the ability to provide family-centered patient care 
that is culturally effective, developmentally and age-appropriate, compassionate, and effective.31 Multidisciplinary 
family-centered rounds provide a venue 
for direct observation of trainees with the chance to observe communication between the attending and families where one can 
witness professionalism, compassion and respect, and improve physical examination skills.32 Discharge Identify discharge needs 
early. Allows for efficient and effective discharge and is vital to 
quality care and patient satisfaction. 
Discuss and address needs early. 
Decreased length of stay and added cost savings are 
associated with same day discharge. Additionally, patients reported high satisfaction with their hospital experience.33 Increasing 
communication between the healthcare team 
and patients leads to positive clinical outcomes, improvement in patient’s perception of communication regarding medications, 
discharge information, and the likelihood to recommend the hospital.34 Utilize discharge needs assessment tools/ 
checklists outlining discharge tasks 
Staff may perceive workload decompression, as tasks are no 
Identify and address specific needs for discharge as they are longer left for 
completion on the day of discharge. 
noted. Allows families to discuss their needs well in advance of 
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 118 
response rate all of whom reported improved intraoperative communication and ease of post-operatively finding families. 
Researchers  in  Shanghai,  China  recently  used  smartphone application technology to assess patient satisfaction.10 Their small 
study  of  ten  patients,  five  caregivers,  and  two  nurses,  focused on patient-reported outcome surveys. Their group believed smart- 
phone  applications  have  the  potential  to  collect  patient reported outcome data with high efficiency and effectiveness. This use of 
technology  can  be  helpful  especially  in  low-socioeconomic  status groups and low-income countries where there are more smart- 
phone  users  than  computer  users.  They  also  felt  mobile  surveys may be the best for reaching children who frequently use smart- 
phones  and  for  collection  of  longitudinal  data  that  require  repeated  survey  completion.  They  altered  patient-reported out- come 
survey  questions  to  be  more  age  specific,  with  caregivers  answering  for  children  5-7  years  old  and  allowing  older  pediatric 
patients  to  answer  for  themselves.10  This  group  subsequently  created an interactive application capable of reading the questions 
aloud  to  help  patients  with  basic  literacy  difficulties  complete  the  survey.  Using  age-appropriate  questions,  decreasing  survey 
length, removing literacy barriers, and making the smart phone accessible surveys may improve satisfaction survey response rates 
and collection of accurate data. 
Some  centers  are  utilizing  virtual  reality  for preoperative patients as well as during some surgical procedures. Distraction and 
virtual  reality  are  an  effective  adjunct  to  pharmacological  interventions  in  reducing  pain.24  Virtual  reality  allows patients to be 
immersed  in a relaxing, peaceful environment.25 It represents a noninvasive way to reduce preoperative stress levels with no side 
effects  and  minimal  need  for  additional  medical  or  paramedical  staff.25  Ford  et  al.  studied  ten  adult  patients  that  used  virtual 
reality  during  burn  care  dressing  changes  in  an  outpatient  clinic  setting,  after  which  they  completed  a  satisfaction  survey  and 
individual  qualitative  interview.24  Quantitative  and  qualitative  results  from  both  patient  and  provider  perspectives  consistently 
supported  the  feasibility  and  utility  of  applying  low-cost  virtual  reality  technology  in  this  setting.24  Application  of  integrated 
technology  and  other  non-conventional  intervention  and  meas-  urement  tools  are  becoming  increasingly  necessary in achieving 
patient satisfaction and improving the perioperative care experience. 
Patient  and family satisfaction are important quality measures, continuously being evaluated and weighed to improve the peri- 
operative  experience.  They  repeatedly  manifest  their  importance  in  evaluating  hospital  and  physician  performance,  in  part  evi- 
denced  by  their  increasing  prominence  in  reimbursement  schemes.  Understanding  the  forces  driving  patient  satisfaction  and 
experience  of  care  can  help  improve  the  patient’s  clinical  course  and  adherence  to  the  discussed  treatment  plans.  Conduct-  ing 
and appropriately interpreting patient satisfaction surveys in the pediatric population provides additional challenges due to the 
Medical discharge criteria defined upon admission and noted in electronic health record 
K.A. Calabro et al. / Seminars in Pediatric Surgery 27 (2018) 114–120 119 
Patient Patient meets discharge 
discharged criteria 
within two hours of meeting discharge criteria (goal) 
Fig. 1. Discharge checklist. 
target’s  age  and  the  additional  need  to  evaluate  caregiver  experi-  ence.  Many  satisfaction  surveys  provide  only  an  illusion  of 
captur-  ing  the  patient  and  caregiver  voice.  Healthcare  providers  and  researchers  must  develop  and  validate  novel  methods  to 
capture  patient  expectations,  perceptions,  and  satisfaction  to  evaluate  the  services  we  provide.  Advances  in  technology  and 
utilization  of  electronic  health  records  may  improve  collection  of  satisfaction  data  and  facilitate  accurate  assessment  of  this 
critical outcome in children’s care. 
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