Better hospitals have happier staff

Better hospitals have happier staff

A new UK study suggests hospitals that perform better have happier staff. Doctors at Imperial College London reviewed satisfaction measures from NHS staff surveys and found hospitals in England with lower mortality rates were more likely to have staff who were happier with the standard of care they provided.

First author Richard Pinder, Honorary Clinical Research Fellow at Imperial's School of Public Health, and colleagues, write about their findings in the 20 February online first issue of BMJ Quality and Safety.

In Wake of Francis Report

The study follows in the wake of the long-awaited Francis report on the inquiry into well-publicized failures at the Mid-Staffordshire Foundation Trust between 2005 and 2009.

Among his recommendations, inquiry chairman Robert Francis QC says NHS trusts across the UK should renew their focus on compassion and creating a caring environment for patients.

The report also highlights the important role that staff play in raising concerns about quality of care, noting that at Mid-Staffordshire, staff who spoke out felt ignored, and there was strong evidence that many were deterred from doing so through fear and bullying.

Francis told the press:

"The Trust's board was found to be disconnected from what was actually happening in the hospital and chose to rely on apparently favourable performance reports by outside bodies such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients."

Staff Satisfaction Linked to Quality of Care

Pinder and colleagues set out to find whether levels of satisfaction in hospital staff, which the NHS assesses through regular staff surveys, were linked in any way to the quality of care they provide.

For their study, they examined satisfaction data from the NHS's 2009 staff survey. This was completed by 60,000 doctors, nurses, admininstative and support staff in 147 acute general NHS hospitals in England.

The researchers were interested in responses to questions that asked staff if they would recommend their NHS trust to a friend or colleague, if they were happy with the standard of care they gave to patients, and whether they felt care was their trust's priority.

They compared the responses to the individual Hospital Standardised Mortality Ratios (HSMRs). This figure is used by the Department of Health to assess hospital performance. A hospital's HSMR is obtained by comparing the expected rate of death with the actual rate of death.

The researchers were not surprised to find that the better performing hospitals were also the ones most likely to have the highest levels of staff satisfaction, and that the strongest link was with nursing staff satisfaction.

But they were surprised to find that hospital performance was just as closely tied to satisfaction levels among non-clinical staff as to those of doctors.

Implications and Next Step

Pinder and colleagues say more studies are now needed to look at the cause and effect nature of this relationship:

"What this work does is demonstrate that staff satisfaction is correlated with organisational performance. The logical next question is about establishing whether happier staff provide better care, or if better care creates happier staff," says Pinder.

He and his colleagues speculate that it is probably a bit of both:

"Better organisations attract better staff, who work harder. It's a cycle of improvement or a cycle of degeneration for many of these hospitals," says Pinder.

There has been much criticism of using HSMRs as a measure of hospital performance, suggesting that it is too crude a measure, but Pinder defends its use for now:

"HSMR isn't perfect, but it's a useful indicator that gives you a steer on performance and has a role in identifying the best- and worst-performing hospitals."

Staff Willingness to Recommend Hospital May Be a Better Measure of Quality of Care

In their paper, Pinder and colleagues suggest staff willingness to recommend their hospital may be a more sensitive indicator of the quality of care than HSMR.

Regular surveys that asked staff "Would you recommend this hospital to friends and family?" might have prevented the failures that occurred at the Mid-Staffordshire trust, says Pinder.

Looking at staff satisfaction indicators might also help patients make better informed choices about hospitals.

"It's difficult for patients to make decisions based on the intricacies of adjusted mortality rates. If you want to choose between two hospitals, knowing that 98% of doctors and nurses working there would recommend their hospital, compared with 60% elsewhere is a useful thing to know," suggests Pinder.

Earlier this month, the University of Stirling announced it is to lead the UK's largest ever study into patient experience and the delivery of frontline health care. The study will involve around 6,000 patients and almost 1,000 nurses and other health professionals over a two year period.

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Section Issues On Medicine: Medical practice