Introduction

According to Wolf et al. (2014, p. 8), patient experience is defined as “the sum of all interactions shaped by an organization’s culture that influence patient perceptions across the continuum of care.” As healthcare organizations strive to enhance the quality of care, the use of patient experience measurement has become increasingly prevalent (Gleeson et al. 2016). Despite this development, there is no universally accepted best-practice method for measuring patient experience (Boylan et al. 2020); therefore, healthcare organizations may employ a variety of different methods for assessing patient experience, such as patient surveys, interviews, complaints and grievances. Over the past decade, a substantial quantity of patient-reported feedback has been collected, particularly in the United States, United Kingdom, and Australia (Sheard et al. 2017). Although healthcare organizations are investing substantial resources to gather this data, including nationally-mandated patient experience measures such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in the US (Rodriguez-Homs et al. 2020), it remains uncertain whether healthcare quality has been improved as a result of increased collection of patient feedback (Coulter et al. 2014).

The present study highlights the importance of identifying the primary determinants of patient experience in order to effectively improve and allocate resources. The examination of these key drivers has primarily been conducted through the analysis of quantitative data obtained from patient experience surveys. However, it has been acknowledged that this approach may not yield sufficient information for meaningful change (Berkowitz 2016). As an alternative, it is suggested that the utilization of qualitative data, such as patient comments, may provide more detailed insights. Therefore, it is recommended that a comprehensive examination of qualitative patient feedback obtained from large-scale surveys be conducted in order to determine the extent to which these data hold valuable insights into the key drivers of patient experience and where quality improvement activities should be directed.

One common method for measuring patient experience is the Net Promoter Score (NPS), which has been widely used in multiple health systems and services, including the United Kingdom’s National Health Service (Manacorda et al. 2017). With NPS, patients provide a rating of their willingness to recommend a service, along with a free-text comment about their score (Krol et al. 2015). Our systematic review of NPS in healthcare found that, while NPS produces a large volume of data that could support quality improvement, these potential gains are not being realized in health services internationally (Adams et al. 2022b). One of the challenges in effectively analyzing the free-text data is that healthcare organizations may not have the resources and/or skills to process and thematically analyze the large volume of patient comments (Adams et al. 2022a). This study aims to identify the key drivers of patient experience from the patient comments and evaluate the usefulness of free-text patient comments for guiding healthcare improvements.

Method

Ethical approval was provided by the participating organization’s local Human Research Ethics Committee (2020/EH01195). The study conducted secondary analysis of cross-sectional survey data (using Net Promoter Score) which was collected for routine patient experience monitoring at one tertiary hospital site in Australia. The NPS survey was sent to all patients (aged 18 to 95) who were admitted to an acute public hospital in Australia. Patients received a text message within three days of discharge from the hospital using the Qualtrics survey system, which contained a link to the NPS survey. 1506 responses were collected during a 6-month period (July to December 2019), which was chosen for analysis to reduce any influencing variables from the COVID-19 pandemic. A random sample of 450 patient comments was selected for analysis, consisting of 150 comments from each of the three NPS subcategories (i.e., negative, neutral, and positive responses).

Thematic analysis

Data analysis was conducting using thematic analysis (TA), which is a technique used to analyze qualitative data and identify patterns of meaning, known as “themes” (Clarke and Braun 2017). In particular, the method of “reflexive thematic analysis” highlights the importance of researcher subjectivity as a resource for analysis (Braun and Clarke 2019). Themes were developed using a six-phase reflexive TA process: (1) data familiarization and writing familiarization notes; (2) systematic data coding; (3) generating initial themes from coded and collated data; (4) developing and reviewing themes; (5) refining, defining, and naming themes; and (6) writing the report (Braun and Clarke 2021).

Two of the researchers analyzed patient feedback using the reflexive TA procedure. According to Braun and Clark (2021), reflexive TA can be deductive, inductive, or both. In this study, a mixed coding (or blended) approach was employed, which is the most common coding method for qualitative analysis (Skjott Linneberg and Korsgaard 2019). Blended coding allows for inherent flexibility in the coding process, with deductive coding providing structure and theoretical foundation, while inductive coding allows researchers to remain open and adaptive to the development of codes (Skjott Linneberg and Korsgaard 2019).

To support deductive analysis, the Picker Principles, which consist of eight dimensions of person-centred care, were used as a framework for TA (Picker 2022), see Fig. 1. The Picker Principles were developed by the Picker Institute, in collaboration with researchers from the Harvard Medical School (Ortiz 2018), and provide a structured approach for understanding patients’ needs and delivering high-quality, person-centred care. The framework was chosen because it has a well-established reputation within the field of patient experience and has been used previously in published research about patient experience (Mills et al. 2014; Kauw et al. 2015; Berrevoets et al. 2018; Bastemeijer et al. 2020)

Fig. 1
figure 1

The Picker Principles of Person Centred Care

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Inductive coding was employed, resulting in the identification of additional codes not identified by the Picker Principles. Both researchers then searched for themes, which were reviewed and discussed, with any divergent views managed by discussion with the co-researchers. In accordance with recommended practice for reflexive TA, themes were iteratively developed and refined throughout the coding process (Braun and Clarke 2021). The themes were defined according to the unified narrative that emerged from the patient feedback data, and the report was written to communicate the findings of the analysis.

Findings

The significant majority (approximately 85%) of the comments were positive and complimentary regarding healthcare delivery. Thematic analysis identified three main themes from the patient comments: (1) Delivering safe, timely, and effective treatment; (2) Fostering human connections with caring and attentive staff; and (3) Providing a comfortable and healing environment.

Theme 1: Delivering safe, timely, and effective treatment

A key theme for the experience of patients was the need to feel safe throughout their hospital stay. The patient comments emphasized the importance of specific moments in the patient journey, such as transitions of care (with admission and discharge processes). In addition, analysis of patient comments indicated that it was important for patients to perceive medical treatment as being both timely and effective, which may be related to their underlying expectations of care. In particular, the following sub-themes were identified:

Feeling safe in hospital

Many patients reported the importance of receiving safe and high-quality care, with positive respondents expressing confidence and reassurance in the care provided. For example, “I felt safe and in great comfort knowing that I was in the best of care in one of Australia’s leading medical institutions.” Typically, patients expressed their feelings of safety in positive feedback in a summative and non-specific way, which was often described as “in good hands.” Conversely, when patients did not feel safe, they often provided specific and detailed explanations about what had occurred.

“Whenever people were involved, I felt like I was in very good hands.”

“I felt very reassured the whole time that I was in good hands.”

“The staff made me feel safe just before and after the surgery and I knew I was in safe hands.”

Ease of hospital transitions

Patients took an evaluative stance on their healthcare encounter from their first interactions with the healthcare organization. Initial impressions appeared to impact the patients’ experience for the duration of their hospital stay, especially those with unplanned hospital admissions. In particular, the process of admission via the Emergency Department (ED) had a significant impact on overall patient experience. Low-rating respondents expressed concerns about the long wait times and discomfort in the ED Wait Room, such as uncomfortable seating. (For example, “I was left in the waiting room for 9 hrs!!! On plastic uncomfortable chairs” and “Wait times excessively long. ER seating layout is horrendous for anyone with mobility issues.”) In addition, patients were particularly concerned if they thought that their health issues were not recognized and prioritized suitably by ED staff. For instance, some patients compared the severity of their illness with other people in the waiting room, making judgements about the fairness and equity of the triage and treatment process (“Five people got a bed before me who had no notable pain”). These comparisons were likely based on observable factors, such as how unwell other patients appeared, which became proxy measures about the quality of the admission process in the ED.

“Waited 6 hours in the emergency waiting area.”

“My waiting time in emergency room was 12 hours.”

“I understand that the Emergency team are busy, but felt that the wait time was totally unsatisfactory, especially given the severity of my injury.”

The findings highlighted the importance of transitions between home and hospital, especially admission and discharge processes. Patients voiced a range of grievances regarding their hospital discharge, which some described as being “delayed and disorganized.” A common theme amongst these concerns was the lack of timely provision of essential items, specifically medications and discharge summaries., Patients expressed concern that this may impair the continuity of care provided by their General Practitioners (GPs) due to the absence of necessary information about their medical condition and treatment.

“Discharge summary not sent to GP from hospital even though went to doctor 5 days after discharge.”

“Had to wait over 6 hours for discharge because of delay in getting medication from pharmacy.”

Effective treatment that meets patient expectations

Patients also expressed concerns about the quality and effectiveness of their treatment, particularly when it did not align with their expectations of hospital care. Reports of dissatisfaction were common among patients who felt that their conditions were not fully addressed or that they did not attain the desired health outcomes. For example, some patients stated that they were “discharged with the same problem I went in for” or that “I left the hospital feeling the exactly same pain I arrived with.” While some patients reported that they received poor quality treatment, this was generally rare. More frequently, concerns about safety were related to perceived omissions of care. Accordingly, evaluation of the quality of care was often based on patients’ pre-existing knowledge and expectations of treatment. For instance, one patient reported “over the weekend, not one doctor came near me and IV drugs and fluids weren’t administered using my cannula.” Medication management was one of the most commonly cited issues, particularly with delays and issues relating to medication prescription and administration.

“The Doctors don’t chart your medications correctly. I had to go without three of mine for two days.”

“I was given an opioid medication when I clearly stated that I was intolerant to opioids.”

Effective management of pain

Patients expressed concerns about treatments that involved unnecessary pain and discomfort. This often related to issues with intravenous (IV) cannulation and blood taking, particularly when repeated attempts were required by clinicians. Overall, pain management was a key topic. Patients were complimentary when hospital staff responded quickly and effectively to their pain, such as “Pain is often belittled in hospitals but my team made me feel like my comfort was their priority.” However, if pain was ignored, devalued, and/or inadequately treated, then this was a source of major dissatisfaction for patients. For example, “I told them it was uncomfortable but no one listened.”

“They tried 6-8 times to take my blood samples.”

“When a doctor came to take blood he missed and spilt my blood all over the bed.”

Theme 2. Fostering human connections with caring & attentive staff

The majority of respondents had positive evaluations of the healthcare professionals they interacted with, using terms such as “kind,” “friendly,” and “caring.” Patients who provided the highest NPS ratings reported favorable interactions with healthcare staff, which they felt contributed to their sense of being valued and treated with compassion.

“Everyone was very friendly and professional.

“I enjoyed that each nurse made the point of connecting with me in their own way.”

“Caring about you as a person, not a number.”

Being informed

Patient expressed how much they valued receiving clear information and being kept informed about their condition and treatment, which was particularly evident in responses by high-rating patients. Patients appreciated being able to understand what was happening throughout their hospital stay and complimented effective communication by healthcare staff. The mode of communicating information was also deemed important by patients, who responded positively when they were given sufficient time to process information and ask questions to staff.

“All the staff were extremely helpful and very thorough in explaining what was going on.”

“The [medical] team were very responsive and informative. I felt I knew what was happening every step of the way.”

“Doctor was great! He explained everything and made me feel comfortable & confident in my care.”

Conversely, patients expressed dissatisfaction if they were not able to gain sufficient information from clinicians, such as “I felt isolated and was not consulted on what was being arranged.” In some instances, staff were perceived as hesitant to provide information and reluctant to address patient queries. For example, “The professor was friendly but not informative and not keen to answer questions”. Additionally, a lack of information was particularly problematic if patients felt like this was due to health professionals not having adequate knowledge about their health condition.

In addition, the comments highlighted a deficiency in providing sufficient information to family members. Notably, this was not frequently commented by patients themselves, but was often reported by the family member who completed the survey on behalf of the patient, typically the next of kin. For example, “As next of kin I still have not spoken to nor met the surgeon despite three procedures in one week.”

“Lack of ongoing communication for patient post operation. It was if none of the nursing staff were able to answer my questions after the operation.”

“A very young doctor arrived. Didn’t know anything about my treatment or any tests to discuss.”

“Felt like no one really knew what was going on.”

Being listened to and valued

Patients emphasized the significance of staff attentively listening to and valuing their concerns, such as “willing to listen to concerns by the patient and act on it.” Conversely, a lack of active listening was identified, particularly among medical staff. For instance, one patient reported “Too many interns who did not listen or take the time to understand my history.”

Responsiveness to patient needs

A prevalent theme in the comments was staff responsiveness. Respondents who were satisfied with their care often noted that staff members identified and met their care needs in a timely and efficient manner. This conveyed that staff members valued the individual needs of patients and made efforts to enhance their comfort and accommodate their requests. However, there were also instances where this level of responsiveness was not met. For example, one patient reported, “I had to keep reminding the staff of things I had asked for or timings of my medication.”

“Extremely professional, polite at all times and nothing was out of the question if they could do it.”

“Very attentive and empathetic staff that were aware of their patients at all times.”

“The staff was just great, taking care of all my needs with great understanding.”

Timeliness of response to call bells was identified as a key area of concern by patients. Positive comments were made regarding staff’s quick response to call bells and frequent check-ins. Conversely, unsatisfied patients were more likely to comment on delays in responding to call bells, particularly regarding issues with pain management and assistance with toileting. The lack of responsiveness to call bells was often attributed to perceived staff shortages, which was a sub-theme that emerged from the thematic analysis. While some patients voiced their concerns about under-resourcing of nursing staff, their attitudes toward the nursing staff remained positive. For example, one patient stated, “Nursing staff were attentive but I thought they were understaffed.”

“Nurses took over half an hour to respond to calls.”

“Lack of staff sometimes was an issue which led to not getting urine bottle when needed and taking a lot of time to get pain relief.”

Providing a consistent quality of care

An important aspect of patient experience was consistency of care quality, which was evaluated from the beginning of their hospital journey. Inconsistencies of care were problematic and staff were perceived as uncaring. A poor attitude by one or two staff members would be highlighted by patients, particularly those providing moderate NPS ratings (i.e., rating 7 or 8). For instance: “95 percent of nursing staff were perfect. One nurse had an attitude problem for absolutely no reason.” Whilst there was recognition of clinical staff, respondents also expressed the importance of all employee interactions, including food services and cleaning staff.

“Couldn’t expect any better service. All the staff were very caring, including the catering, cleaning etc.”

“Everyone from anaesthetist to cleaners was friendly, kind and treated me with respect and consideration.”

Theme 3: Providing a comfortable & healing environment

Several comments were made about the physical hospital environment, including spaciousness of the patient rooms (e.g., “Large room with space” and “The new ward is beautiful and all new”), and the ability to connect with the environment and nature.

“I had lovely room & big window view in the ward post-surgery. Being able to see the sky makes a big difference.”

“Having a room overlooking a park and trees helps restore the soul.”

Having a clean and functional room

Negative comments about the hospital environment were often made about issues with facilities maintenance. For instance, “The ward whilst spacious was not great. The light in my cubicle did not turn off so had to sleep with it on.” Patients expressed concerns when maintenance issues were reported but not fixed. (For instance, “The toilet did not work and the building management didn’t seem to fix it the whole time I was there.”). Patients made positive comments about having a clean and comfortable hospital environment; however concerns were reported when cleanliness was not maintained, such as “Nobody came to clean the room for 4 days and my bed was also never made until I mentioned it to one of the nursing staff.” A common area of concern about lack of cleanliness was the toilet, particularly in shared rooms. One patient noted, “Bathroom/toilet facilities are communal in nature & are not maintained at optimum levels of hygiene.”

Promoting sleep and rest

In addition, patients commented about the importance of sleep and bedding, including bed size and comfort (“My bed was too small”, “My mattress didn’t properly fit my bed” “Didn’t even have enough pillows to go around” and “Beds are hard. The blankets weigh 3 tonnes”). Patients reported disturbances to sleep, which was often due to excessive noise in the wards at night.

“The place was extremely noisy at night.”

“I was in a 4 bed ward and two patients at different times during the night had their TVs blaring which interferes with my sleep.”

“Unable to rest with noise of other patients and night staff laughing and talking up and down the halls.”

Providing nutritious food and dietary options

The topic of hospital meals was mentioned most by respondents who gave a moderate NPS rating. Whilst patients expressed comments about food quality, taste, and variety of meal options (“The care is 100% but the food quality is what lets you down”), they also valued the implications of food on their health and recovery. For instance, food was assessed for nutritional value and whether the food was suitable for their clinical conditions (e.g., “The food was not at all adapted to diabetics”).

Discussion

The collection and reporting of patient experience data is a costly and resource-intensive activity, which has limited evidence of its impact on patient safety and quality outcomes (Coulter et al. 2014). Many healthcare organizations focus on the collection and reporting of quantitative data, such as patient surveys (Beattie et al. 2015); however, the results of this study have identified that qualitative feedback may also serve as an important data source. When properly analyzed, qualitative data can provide valuable insights into patient experiences and inform quality improvement efforts in healthcare. The majority of patient comments were positive, which is consistent with previous research conducted in the Australian context (Harrison et al. 2017).

Specific aspects of the healthcare journey were found to be closely linked to patient experiences of care, with the identification of various key drivers of patient experience, including perceptions of safety, timeliness, effectiveness, comfort, and compassion in the care process. Our thematic analysis of patient comments identified a range of factors that influence patient experience, which can be grouped into three interconnected themes: (1) the provision of safe, timely, and effective treatment; (2) the fostering of human connections with caring and attentive staff, and (3) the provision of a comfortable and healing environment.

Patients often described safety by using generalized terms and metaphors (such as feeling “in good hands”), which lacked specificity about the exact staff behaviors and care processes that contributed to their perceptions. In addition, patient comments about quality and safety issues often related to perceived omissions of care, whereby patients did not receive the form of care that they expected. For instance, these issues were frequently associated with perceived delays in treatment, such as long wait times in emergency departments. Patients presenting to ED were often more critical in their NPS rating and comments, which appeared to be worsened by the discomfort they felt while waiting. Patients also commented about unnecessarily waiting during their discharge from hospital; however, these were not perceived as harshly as ED wait issues, with some patients still providing high NPS ratings despite their concerns.

The results of this study suggest that quality and safety issues tend to involve aspects of care that patients can readily observe and/or have prior knowledge about. For example, patients often commented on issues related to their medications, such as dosage and administration times, which they may be familiar with. Patients’ perceptions of quality were mainly influenced by their direct experiences, particularly the management and reduction of pain (including avoiding unnecessary procedures, such as repetitive IV cannulation and blood tests). Although the majority of comments could be coded according to the Picker Principles, the analysis revealed an additional theme of “staff shortages,” which may indicate that issues related to healthcare resourcing are having a progressively detrimental impact on patients’ experiences.

The analysis of patient feedback revealed several key areas of focus for patients. Firstly, patients expressed an appreciation for features that connected them to nature, such as large windows, natural light, and views of trees, as well as a clean and well-maintained environment. Patients reported dissatisfaction with maintenance and cleanliness issues that were not addressed promptly. Additionally, patients placed high importance on adequate sleep and rest, expressing dissatisfaction when this was negatively impacted and disrupted. Nutrition and diet were also highlighted as important factors for healing and recovery, with many patients commenting about the nutritional value and variety of hospital meals, not just food quality and taste.

Patients who had positive experiences often cited the quality of their interactions with both clinical and non-clinical staff as a key factor. However, when care was perceived to be inconsistent, it had a negative impact on the patient experience. This was often due to the actions of a single staff member. Patients often focused on these negative interactions, which they perceived as “not caring.” Analysis of the patient comments indicates that patients place a high value on effort over outcomes. Accordingly, patient satisfaction is not solely dependent on the complete fulfillment of all patient’s needs, but rather on the visible effort made by staff to address concerns raised by the patient. This finding has important implications for healthcare providers, as it suggests that a focus on visible effort to address patient concerns may be a key factor in improving patient experiences.

Implications for quality improvement

The results of this study demonstrate the utility of analysing qualitative data in order to support quality improvement efforts and identify specific issues impacting the patient journey. However, it is important to note that the analysis of such data can be quite time and resource intensive, particularly due to the large volume of qualitative data collected by healthcare organizations. In order to streamline this process and prioritize the analysis of qualitative data, it was identified that negative feedback is generally more useful for quality improvement purposes, as it tends to be more specific and descriptive than positive feedback. While positive feedback often relates to the overall experience of care, it often lacks detailed information. Additionally, examination of NPS comments only resulted in the identification of one clear suggestion for improvement. As such, to increase the amount of suggestions for improvement, healthcare organizations should consider incorporating specific questions into their patient feedback surveys, such as: “How could our services be improved?"

The Three Pillars of Patient Experience

Based on the findings of this thematic analysis, we have developed a conceptual framework known as The Three Pillars of Patient Experience to guide quality and service improvements in patient experience (as illustrated in Fig. 2).

Fig. 2
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The Three Pillars of Patient Experience

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The findings of this study suggest that the probability of a negative patient experience being reported increases in proportion to the number of areas (“pillars”) affected by issues. To guide patient experience improvement activities, therefore, healthcare organizations can focus on improving one or more of the patient experience pillars. For example, in the Emergency Department, if ED wait times cannot be reduced, then improvement activities can focus on the other pillars – such as enhancing the comfort and cleanliness of the ED environment, keeping patients informed, and quickly and effectively responding to patient needs. In general, quick improvements in the patient experience can be attained by focusing on tangible environmental factors, such as comfort, cleanliness, and noise levels, which are categorized in Pillar 3.

Limitations

Limitations for this study include a focus on feedback from the NPS survey, which does not include other sources of free-text patient comments, such as patient complaints and grievances. Also, patient comments may not necessarily be representative of the patient population as they may be biased toward those who are literate and English-speaking; hence further research could explore the experience of patients from Culturally and Linguistically Diverse (CALD) backgrounds. This study was conducted in a public hospital located in Australia, therefore there could be variations in patient experiences in other countries due to cultural differences. There may also be differences between the experiences of patients with planned and unplanned hospital admissions, so this is recommended as an area for future research. Finally, the analysis was based on comments collected before the COVID-19 pandemic and may not reflect changes in patient’s health-related attitudes, expectations, and needs that have evolved since this time.

Conclusion

In conclusion, this study aimed to evaluate the use of qualitative feedback for quality improvement purposes and identify the key factors that affect patient experience. The results suggest that qualitative data can provide valuable insights for improving patient experience, and that negative feedback, in particular, is more specific and useful for quality improvements. Furthermore, our findings indicate that the primary factors influencing patient experience in hospital can be grouped into three interconnected themes: (1) the provision of safe, timely, and effective treatment; (2) the fostering of human connections with caring and attentive staff, and (3)the provision of a comfortable and healing environment. Based on these findings, a conceptual framework titled “The Three Pillars of Patient Experience” has been developed to guide improvements in patient experience.