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JACK BOEPPLE KEL740

Analyzing Low Patient Satisfaction at Herzog

Memorial Hospital

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If you don’t know where you are going, any road will get you there.
—Lewis Carroll

Christmas 2012 was approaching and Jeri Tinsley, director of medical, surgical, and intensive
care services at Adeline Herzog Memorial Hospital, was concerned. The Press-Ganey scores for
the third-floor nursing unit—the destination for 70 percent of patients admitted through the
emergency department—were at the 15th percentile, and a key HCAHPS (Hospital Consumer
Assessment of Healthcare Providers and Systems) score for inpatients (“The area around my
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room was quiet at night”) was well below the Colorado average. Over the past six months Tinsley
had made various changes to try to improve the patient satisfaction scores for her 32-bed unit, but
the scores seemed stuck at an unacceptably low level.

She had asked Maddie Rose, the new third-floor nursing manager, for help. Rose had
experience with data analysis and analytical tools that were used to analyze qualitative data,
particularly affinity and Pareto diagrams.
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Tinsley worried that if improvements were not made soon, patients would start “voting with
their feet” and take their business to competing hospitals. As a registered nurse, Tinsley’s
expertise was helping people heal; it was not analyzing data. In particular, she was overwhelmed
by the patient comments included in the surveys; she could not decide which issues to address
first (see Exhibit 1, the spreadsheet that accompanies this case).
No

Adeline Herzog Memorial Hospital

Adeline Herzog Memorial Hospital was a 95-bed community hospital located in Castle Rock,
Colorado, midway between Denver and Colorado Springs. The hospital had been established
forty years earlier, when the community was relatively isolated, to provide local access to
healthcare services. As Denver expanded south and Colorado Springs north, and as the region’s
population grew, other hospitals entered the market. Although it had been a fixture in the
community for decades, Herzog was not performing well against its new competitors—in 2012,
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for the second straight year, the hospital experienced a decrease in revenue and admissions.

©2013 by the Kellogg School of Management at Northwestern University. This case was prepared by Professor Jack Boepple. Cases
are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or
illustrations of effective or ineffective management. To order copies or request permission to reproduce materials, call 800-545-7685
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photocopying, recording, or otherwise—without the permission of Kellogg Case Publishing.
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 HERZOG MEMORIAL HOSPITAL KEL740

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Water was a source of numerous (and constant) complaints from Herzog patients. Supplied

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from the hospital’s own well, the water, while potable, was discolored due to high iron content
and often had an unpleasant taste and smell. Further, it stained the facility’s toilets, sinks, and
showers and made cleaning them a major headache. Herzog management planned to address the
issue in 2013 by digging a deeper well.

Facilities were also a challenge. The newer hospitals had 100 percent private rooms, but

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because it was an older hospital, Herzog had inpatient rooms that were semi-private (two beds per
room). In particular, the third-floor nursing unit had 32 beds: only four were in private rooms.
Herzog management had originally planned to undertake renovations to address this issue in
2012, but the downturn in revenue delayed the planned renovations; the current target date to start
the renovations was 2015.

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Press-Ganey
Press-Ganey worked with 10,000 healthcare organizations across the United States—
including 50 percent of all U.S. hospitals—to improve clinical and business outcomes. It offered
a wide range of performance improvement services, but the most popular was a database that
offered hospitals a way to benchmark their performance against a group of competitors they
selected. Percentile ranking was used as the comparative measure. For example, an 80th-
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percentile score on the dimension “friendliness/courtesy of the nurses” meant that the hospital
scored higher than 80 percent of the other hospitals within the comparison group—the higher the
percentage, the better the result.

Along with the percentile ranking Press-Ganey offered detailed reports, including prioritized
improvement recommendations. Hospitals also had access to all of the comments. These
comments were grouped in various, survey-defined categories (such as admission, room, meals,
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nurses, tests and treatment, visitors and family, physician, discharge, personal issues, and overall
assessment). Within these categories, the comments were further classified as (1) positive, (2)
negative, (3) mixed, and (4) neutral.

Patient satisfaction data was collected using a survey sent to a random sample of patients.
The quantitative part of the survey asked patients to rank their experiences on a scale from 1
(Very Poor) to 5 (Very Good). The five-point scale was translated into a score between 1 and 100
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(see Table 1).

Table 1: Press-Ganey Scale and Score

Very Poor Poor Fair Good Very Good
Scale 1 2 3 4 5
Score 0 25 50 75 100
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Overall inpatient satisfaction for all of Press-Ganey’s clients increased from 2006 through
2010, with an overall rating between Good and Very Good (see Figure 1). Herzog’s overall score
was 86.0, which put it between Good and Very Good, but it was in the 15th percentile, which
revealed it was doing poorly relative to the other hospitals in its comparison group.

2 KELLOGG SCHOOL OF MANAGEMENT

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 KEL740 HERZOG MEMORIAL HOSPITAL

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Figure 1: Press-Ganey Inpatient Satisfaction Score for All Clients

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Overall Patient Satisfaction
86.5 86.0 86.1

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86.0 85.5 85.6 85.6
85.3
85.5 85.0 85.1
85.0 84.7 84.7 84.7
84.4
84.5 84.1 84.1 84.2 84.3 85.0

84.0 84.4
84.1
83.5 83.9

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83.0
82.5
Jan‐06
Apr‐06
Jul‐06
Oct‐06
Jan‐07
Apr‐07
Jul‐07
Oct‐07
Jan‐08
Apr‐08
Jul‐08
Oct‐08
Jan‐09
Apr‐09
Jul‐09
Oct‐09
Jan‐10
Apr‐10
Jul‐10
Oct‐10
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Source: Press-Ganey, 2011 Pulse Report, http://www.pressganey.com/Documents_secure/Pulse%20Reports/2011_Press_Ganey_Pulse_
Report.pdf?viewFile, p. 15.

HCAHPS
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The HCAHPS (pronounced “H-caps”) survey was the first publicly reported and standardized
national survey of patient perspectives of hospital care. HCAHPS was a 27-item survey
instrument and data collection methodology. Many hospitals collected information on patient
satisfaction for their own internal use, but until HCAHPS there were no common metrics and no
national standards for data collection and public reporting. Available since 2008, HCAHPS
allowed valid comparisons to be made across hospitals locally, regionally, and nationally.

HCAHPS also used random surveys to collect patient satisfaction data.1 Patient experience
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questions asked patients to rank their experiences on a scale from 1 (Never) to 4 (Always). The
scale for rating a hospital overall ranged from 0 (Worst Hospital Possible) to 10 (Best Hospital
Possible). HCAHPS provided no space for free-form comments.

All of the individual HCAHPS scores for Herzog were within three points of the Colorado
average, except for one: Herzog’s score for “The area around my room was quiet at night” was 14
points below the Colorado average. One of the new competitors scored 12 points above the
Colorado average for that question.
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1
A sample survey can be found at http://www.hcahpsonline.org/surveyinstrument.aspx.

KELLOGG SCHOOL OF MANAGEMENT 3

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 HERZOG MEMORIAL HOSPITAL KEL740

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Analyzing Qualitative Data

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We have few agreed-on canons for qualitative data analysis, in the sense of shared
ground rules for drawing conclusions and verifying their sturdiness.
—Miles and Huberman, 1984

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Rose reassured Tinsley that her reaction was not unusual: good nurses tend to identify
problems and immediately react to address them. However, the large number of patient comments
from the surveys meant that it was not feasible to address each one individually. The key, Rose
explained, was to look for patterns or trends and start by addressing the biggest or most common
complaint and then moving on to the next. She likened the approach to eating an elephant “one
bite at a time.”
She explained that in contrast to quantitative (or objective) analysis, in which numbers are the

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material to be analyzed, in qualitative (or subjective) analysis the object of analysis is words.
Although it is guided by fewer universal rules and standardized procedures, qualitative analysis
requires data to be organized into logical groupings. Rose quoted Miles and Huberman, who
described this as “the process of selecting, focusing, simplifying, abstracting, and transforming
the data that appear in written-up field notes or transcriptions.”2 Not only does the data need to be
condensed for the sake of manageability, it also must be transformed so it can be made
intelligible in terms of the issues being addressed.
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Rose then introduced one analytical tool to help Tinsley manage the patient comments: an
affinity diagram. She described an affinity diagram as a visual tool that synthesizes large amounts
of data by finding natural relationships—or “affinity”—between individual data points. As shown
in Figure 2, an affinity diagram arranges random ideas (each represented by a yellow sticky note)
into logical themes.

Figure 2: Graphical Representation of Affinity Diagram

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    Random Ideas              Affinity Diagram

Theme Theme Theme

1 2 3
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Source: Based on “Affinity Diagrams: Organizing Ideas Into Common Themes,” MindTools, http://www.mindtools.com/pages/article/
newTMC_86.htm (accessed December 11, 2012).
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2
Susan Berkowitz, “Analyzing Qualitative Data” in User-Friendly Handbook for Mixed Method Evaluations, National Science
Foundation, August 1997, http://www.nsf.gov/pubs/1997/nsf97153/chap_4.htm, quoting M.B. Miles and A.M. Huberman, Qualitative
Data Analysis (Newbury Park, CA: Sage, 1984), p. 16.

4 KELLOGG SCHOOL OF MANAGEMENT

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 KEL740 HERZOG MEMORIAL HOSPITAL

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Themes identified in an affinity diagram could be used as the basis for another tool, a Pareto

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diagram, which ordered the themes from highest frequency to lowest. This technique was named
after Italian economist Vilfredo Pareto, who observed in 1906 that 80 percent of land in Italy was
owned by 20 percent of the population. In the 1940s management consultant Joseph M. Juran
applied the Pareto principle to quality issues to identify the 20 percent of causes (the “vital few”)
that were responsible for 80 percent of the results (see Figure 3).

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Figure 3: Sample Pareto Diagram

100%
250 90%
80%

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200

Cumulative Percent
70%
60%
Number

150
50%
40%
100 Vital few Trivial many
30%
20%
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50
10%
0 0%
Parking Rude sales Poor Confusing Limited Clothing Clothing
difficult rep lighting layout sizes faded shrank
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Count Cumulative Percent

Source: Based on “Pareto chart (Pareto distribution diagram),” WhatIs.com, http://whatis.techtarget.com/definition/Pareto-chart-Pareto-

distribution-diagram (accessed December 11, 2012).

Taking Action
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We can’t solve the problems of today by using the same kind of thinking we used when we
created them.
—Albert Einstein

As Rose concluded her training, Tinsley felt more comfortable about her own ability to
organize and make sense out of the various patient comments, and then identify the most
important themes so she could focus on them rather than the multitude of exceptions.
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After she completed the unfamiliar diagrams, Tinsley felt like she finally had the last piece of
the puzzle. Used in conjunction with quantitative analysis from Press-Ganey and HCAHPS, she
believed she could develop a more specific (and a more manageable) approach to improve patient
satisfaction for the third floor.

KELLOGG SCHOOL OF MANAGEMENT 5

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Permissions@hbsp.harvard.edu or 617.783.7860