Posted: March 23rd, 2023



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The performance of hospitals is critical in determining their effectiveness and impact in meeting the needs of the patients. Patients are the most important stakeholders in the care process, and the hospitals should always seek to provide positive experiences by providing them with the utmost level of quality and safe care. Hospitals, even in the same region, do not perform at the same level looking at different performance measures. Data collected using the measures indicates the level of performance for the different hospitals. It is from this point of view that data from three hospitals in Florida, including Physicians regional medical center Pine Ridge, Naples Community Hospital, and GULF COAST MEDICAL CENTER LEE MEM HEALTH SYSTEM are compared.

The Purposes of the Patient Hospital Experiences Data

The patient information relating to the care providers has significance to different stakeholder groups, who use the data for different purposes. For the patients, the information is empowering as it gives them a voice in their care process (Cosgrove, Crowley, & Martin, 2017). When the patients are given the chance to use the data to make decisions relating their care, the chances for abuse are reduced.  For the health care providers, the data is an important source of insights to improve the quality of their services. The data is collected for many hospitals, making the competition a motivator for the hospitals to continue improving their services. Striving to raise the standards makes it possible for the patients to enjoy better quality and safer services. When making policies relating to health care services, the government makes use of the data. It is important for the government to be aware of the kind of experiences the patients are having in line with the quality standards set at the national and state levels.

The Impact the Scores on Hospital Operations and Finances

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Hospitals are always striving to get the highest score in the rating of their services based on the patient experiences. The scores have huge implications in the current world where the patients have a better understanding of their right to safe and quality care. The scores play an important role in decision-making on the part of the patients. In this case, patients and their families use the scores to rate the health care facilities and to make the decision on whether to use the services of one facility over another. Hospitals with the highest scores are most preferred by the patients, which translates to better results in terms of operations. In most cases, when evaluating alternatives, the rating of the hospital is a more important factor than the cost of care. The financial implications of a good score are twofold:  the users of the healthcare services are prepared to pay the cost of quality and safe care, and investors are most likely to pay more for hospitals with a good score.

Patient Hospital Experiences of Care (HCHAPS)

The scores under the Patient Hospital Experiences of Care are given under a number of a number of statements. The table below is a comparison of the three hospitals, and to the state and national average (, 2017).

Statement Physicians regional medical center Naples Community Hospital GULF COAST MEDICAL CENTER Florida average National average
Patients who reported that their nurses “Always” communicated well 67% 72% 74% 77% 80%
Patients who reported that their doctors “Always” communicated well 75% 75% 71% 78% 82%
Patients who reported that they “Always” received help as soon as they wanted 53% 55% 59% 62% 69%
Patients who reported that their pain was “Always” well controlled† 61% 63% 65% 68% 71%
Patients who reported that staff “Always” explained about medicines before giving it to them 52% 55% 57% 61% 65%
Patients who reported that their room and bathroom were “Always” clean


62% 62% 68% 69% 75%
Patients who reported that the area around their room was “Always” quiet at night


63% 48% 53% 59% 63%
Patients who reported that YES, they were given information about what to do during their recovery at home 82% 82% 87% 85% 87%
Patients who “Strongly Agree” they understood their care when they left the hospital


43% 43% 49% 50% 52%
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) 63% 61% 69% 68% 73%
Patients who reported YES, they would definitely recommend the hospital 64% 63% 72% 70% 72%


Survey of Patients’ Experience

The results from the table indicate that there are some areas where Physicians Regional Medical Center Pine Ridge is rated better than Naples Community Hospital and GULF COAST MEDICAL CENTER LEE MEM HEALTH SYSTEM, but there are many other areas that the hospital rates the worst compared to the two and the national average. In terms of the communication between the patients and nurses, the hospital rates the worst compared to the other two, the national and state average. In terms of communication between the patients and the nurses, the hospital rates the same as Naples Community Hospital, but higher than GULF COAST MEDICAL CENTER. However, the score is lower than the national and state average. The hospital rates the lowest in comparison to the two and to the averages in terms of urgency of help. In terms of control for pain, the hospital also rates the lowest. It is the lowest in terms of information on drugs given to patients before administration. Together with Naples Community Hospital, the score on the cleanliness of the room and bathroom, effective transition to home care are lowest. In terms of the quietness around the hospital, Physicians Regional Medical Center Pine Ridge rates higher than the other two and the Florida average. The overall rating and possibility for recommendation of the hospital are low, but only slightly higher than Naples Community Hospital ( 2017). Overall, Physicians Regional Medical Center Pine Ridge has a low score compared to the other two, and to the national and state average.

Importance of the Results

The results of the analysis of the score have important ramifications for the hospital given the fact that the information is the basis for decision-making by the consumers and the policymakers. In terms of the operations, the data plays a role in improving the operations or risk losing the patients to the other hospitals that have a higher score. Patients and policymakers are the sources of finances for hospitals. The score has to be higher compared to those of the competitors if the hospital has to attract more finances. Enhancing the quality and safety of the hospital is the basis for the improvement of the score. The rating will only improve if the hospital will improve the general experience of the patients by making all the aspects of the care process better. The scores indicate where the hospital is in relation to competition as the basis for improving the services.

Rationale for Selection of Criteria

The quality of care remains an important element of the care process. Although major improvements have been made within the healthcare, the delivery of quality care has remained questionable. Patients are the source of the important insights on the quality of care, which forms the basis for effective improvement. In addition, the experience of the patients is the basis for understanding the quality of care. Health care can be argued to meet the quality of care standards if the experiences of the patients are positive. Given the important role that patients’ experience is high, other aspects of the care process can be said to be positive (Beattie, Murphy, Atherton & Lauder, 2015). The experience is the view of the patients about the quality of care. The views have an important role to play and should be taken into consideration in the hospital improvement plans. Valid and reliable information on patients’ experience is useful in care improvement plans.

The Specific Steps in the Plan for Improvement

The plan for improvement will be based on the steps for improving the experience of the patients receiving care in the hospital by impacting on the quality of care. In this case, PDSA (Plan, Do, Study, Act) is the model of quality improvement that will be used in the change process. It will be the basis for the achievement of the necessary ongoing quality improvement in the hospital. The team for the implementation of the change will be constituted that will be engaged in planning. The planning stage will be the phase for the selection of ideas for the improvement. The concepts will come from the members of the clinical team as well as from the patient surveys indicating areas that need to be improved. Do is the implementation phase of the quality improvement plan. This is the phase where the plan of action is communicated to the members of the team. A discussion on the adoption of the change, including the success factors and the handles, is held. Once the change is adopted, “Study” involves measurement of the outcome. Evaluation is critical to establish the potential for the change to achieve the objectives (Ho, Principi, Cordon, Amenudzie, Kotwa, Holt & MacPhee, 2017). The “Act” involves the continued improvement of the change once it has been adopted.

Timeline for Implementation of the Proposed Improvement

The change is urgent to ensure that the rating of the hospital in terms of the experience of the patients goes up. Therefore, it is necessary that the measures for the improvement of the quality of care to the patients are implemented in the shortest time possible. One month is adequate for the successful implementation of the change. Within one month, the necessary resources for the training of the nurses will be acquired, and the training carried out. By the end of this period, the nurses will have been equipped with the information necessary to provide quality of care and improve the level of satisfaction of the patients (Easton, O’Donnell, Morrison & Lutz, 2017). As long as the patients are receiving quality care, the surveys they complete will have positive results. This way, the hospital will rate better compared to the competitors.

Time Frame for Measurement of Results

After implementing the training program for the nurses to improve the quality and safety of care for the patients, it will be necessary to find out whether the objective of improving the score of the hospital has been achieved. This forms the basis for the evaluation of the outcome of the implemented program (Brandrud, Nyen, Hjortdahl, Sandvik, Haldorsen, Bergli, & Helljesen Haldorsen, 2017). The program will be evaluated in the second month of the implementation. It is expected that after implementation and during the first month, the nurses will be ready to provide quality and safe care to the patients during the second month. The results will be seen by the end of the second month. The data for the evaluation will be collected from the website from where the possibility for a new score will be indicated. If the new score will be higher than it was before the implementation of the change, it means the objectives have been met and the effectiveness will be confirmed. The program will be part of the continued change process. If there will be no noticeable change or a decline in the score is noted, it means that the change will not have achieved the objective. The program, therefore, will have to undergo more changes for continued improvement.



Tools or Projects to be used in the Plan for Improvement

The project that will be used in the change is a training program aimed at the nurses and other hospital staffs directed at improving the quality and safety of care at the hospital. Training resources will be acquired by the hospital administration for use in the implementation of the project. Among the resources that will be required include computers and projectors for use in passing the information to the participants. There will be trainers from inside and outside the hospital who will be training the nurses on the measures to improve the quality and safety of care for the improvement of patient experience. The financial and other resources should be made available before the beginning of the training sessions.

“Promotion” of the Plan

Resistance to the change is the greatest barrier to the implementation of the proposed change. Hence, it is critical for the implementers of the change to ensure that all the stakeholders are in support of the change process for it to be effective. A cost-benefit analysis is always the most effective way of convincing the management and the other members of the organization who will be affected by the change. From the cost-benefit analysis, there will be a list of the costs and the anticipated benefits. The implementing team should be able to prove that the expected benefits outweigh the costs. This way, it becomes easier to attract investment in time and resources, and the general support for the project from all the stakeholders. Involving them during every phase of the project is another effective way of gaining the support. The management and other stakeholders need to see results every step of the way to support the change.


For the patients, evidence of the quality of care even as hospitals strive to provide patient-centered care in a more open environment is critical. At the same time, patients have become more informed about their right to safe and quality care. The website is a source of rating for hospitals based on a number of criteria. From the website, it is possible to compare hospitals and propose measures for improvement for the hospitals that have low scores. The proposed change process for Physicians Regional Medical Center is a training program targeted to the nurses and other members of staff to improve the quality of care, hence, the potential for increased rating.

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