Make Patients Happy: A Simple Alternative to Patient Satisfaction Surveys

By Dr. J. Gnanaraj and Ms. Danita Gnanaraj

How do you keep your patients happy? The Medical Group Management Association (MGMA) published a report showing that almost 80 percent of better-performing practices used surveys to measure patient satisfaction (1). These practices also used surveys more often than others. Surveys improve communication with patients and may increase patient retention – and some countries even require patient surveys to be taken.

There are several factors to consider while doing a patient satisfaction survey. Brevity, clarity and consistency are considered very important, among the many factors that are to be considered while doing the surveys (2).

Pulse evaluationHowever, carrying out surveys can cost both money and time. We describe a simple method that we used in the mission hospital to replace our extensive 26-question patient satisfaction survey. It involves the use of the patients’ pulse rates, measured at the beginning by the nurses recording the vital signs, then measured again after the doctors’ consultation and another measurement at the exit interview time.

The Method

In the first phase of the study, patient satisfaction surveys were carried out by nurses from CMC Vellore and nursing students from Burrows Memorial Christian Hospital. The surveys were based on the experiences at various counters of the hospital, and the patients’ pulse rates were checked both before and after the various parts of their visits, like being examined by the doctors, at the laboratory, at the preliminary examination counters where the patients interact with the nursing staff, and so on.

All of the surveys were carried out at the end of the day, but independent evaluators checked the patients’ pulse rates at each counter or place before and after each visit. The results were analyzed to determine the correlations (3).

In the second part of the study, we reviewed the data from the electronic records of the in-patients at the mission hospital in Assam. The system had a 26-question patient satisfaction survey randomly printed out for 10% of the admissions, using a random number table that the computer system chooses, when it prints out the forms along with IP charts. The survey results were then compared with the initial recorded pulse rates by the nurses entering the vital signs and the last recorded pulse rate in the chart.

In the third part of the study, the pulse rate at the vital signs entry and after the patients are told about the recommended surgical procedure was compared with their consent for the procedures.
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In the first part of the study, it was found that when patients’ pulse rates decreased, there was a 95% chance that the patient reported feeling “good” or “excellent” about the experience. When patients’ pulse rates increased, there was a 67% chance that the patient would report a “poor” or only “satisfactory” opinion about the visit. Treating a decrease or lack of change in the pulse rate as an indicator, we found that positive experiences could be predicted based on the following figures:

Sensitivity = 80%
Specificity = 80%
Positive predictive value = 88.9%
Negative predictive value = 66.7%

Alternately, the following figures were obtained for predicting less-satisfactory experiences:

Sensitivity = 80%
Specificity = 80%
Positive predictive value = 66.7%
Negative predictive value = 88.9%

In the second part of the study, 73% of those who had completed the patient satisfaction survey were satisfied with the services. This was out of 13,640 records over a seven-year period, which were analyzed through the software. All the patients had either lower or the same pulse rate recorded, when looking at the first and last pulse rate record using the software. However, only 65% of the survey forms were filled, and only 48% of these were finally entered in the software. The above figures were obtained by manually going through the charts of 1,000 patients over a one-year period.

In the third part of the study, 2,611 patients were advised surgical procedures during the surgical camps during the last 5 years. Of these, 2,042 agreed to the surgical procedures and had them carried out. The records of the 569 patients who refused surgical procedures showed that all of them had higher pulse rates, compared to the earlier recorded pulse rates at the time of registration. The pulse rate of others was not analyzed, as many of the patients who had surgical procedures were not discharged, and their charts were not maintained in the usual software.


Patients’ opinions and feedback are important for improving quality in a clinic or hospital (4). In France, hospitals have been required to measure satisfaction since 1996 (5). This has caused an increase in research on the concept of satisfaction (6), determinant of satisfaction (7-8), and development of standard or generic in-patient satisfaction questionnaires (9-11). Still, there is controversy over effectiveness of measuring feedback from patients to improve skills of doctors and staff, based on varied interpretation of the survey data (12).

The increase in heart rate due to any stress is mediated by Parasympathetic Nervous System (13). There is a significant amount of stress around health conditions, especially for surgical patients who are waiting to see the doctor. However, if they are happy with the explanations and have confidence that a good job would possible at the facility, the stress is decreased. However, the stress remains if they are not satisfied. This leads to the increase in pulse rate.

Although they are not consistently used, patient satisfaction surveys are important. They can improve the available services in a clinic or hospital. However, the drawback is the time and money involved in getting the surveys carried out. The patients’ pulse rates could be used as a simple screening method, and those who are stressed or have an increased pulse rate can be asked to give more information about the areas that need improvement.


The pulse rate change could be used as a simple and easily carried out assessment tool for patient satisfaction. It would be very effective as a screening process.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
Danita Gnanaraj-64 Ms. Danita Gnanaraj did her Electronics and Instrumentation Engineering from Karunya University. Her experience at several remote and rural mission hospitals motivated her to spend more time with the department in designing low cost equipment for the poor and needy in mission hospitals. She was part of the team that designed the low cost topical vacuum therapy unit and patient monitoring systems. After gaining experience in Capgemini regarding computer software she is currently working with Ms. STAAN at a bio-medical engineering company.

Image: Pulse evaluation. Author: Pia von Lützau. 2009. Access the original Image information here:

References (click to show/hide)

  1. MGMA benchmarking report: Almost 80 percent of practices deemed ‘better-performers’ conduct patient-satisfaction surveys. Available from: (accessed on June 25, 2015).
  2. Brandi White. Measuring Patient Satisfaction: How to do it and Why to bother. Fam Pract Manag. 1999 Jan;6(1):40-44.
  3. Gnanaraj J, Raja P, Balaji P. Muthulakshmi, Ghosh S. Patients pulse rate: Indicator for patient satisfaction assessment. Rural Surgery, Vol. 5, No. 4, October 2009, pp. 8-10.
  4. Levine AS, Plume SK, Nelson EC. Transforming patient feedback into strategic actions plans. Qual Manag Health Care 1997; 5: 28–40.
  5. Code de la Santé Publique. Ordonnance no 96–346 du 24 avril 1996 portant réforme de l’hospitalisation publique et privée. Journal Officiel de la République Française (Paris) 1996: 6324–6336.
  6. Pourin C, Barbeger-Gateau P, Michel P et al. La mesure de la satisfaction des patients hospitalisés: aspects conceptuels et revue des travaux. Journal d’Economie Médicale 1999; 17 101–115.
  7. Salomon L, Gasquet I, Durieux P et al. Prise en compte des attentes des patients pour améliorer la qualité des soins. Rev Epidémiol Santé Publique 1998; 46: 427–429.
  8. Thi PL, Briancon S, Empereur F et al. Factors determining inpatient satisfaction with care. Soc Sci Med 2002; 54: 493–504.
  9. Salomon L, Gasquet I, Mesbah M et al. Construction of a scale measuring inpatient’s opinion on quality of care. Int J Qual Health Care 1999; 11: 507–516.
  10. Auquier P, Blache JL, Colavolpe C et al. Échelle de vécu périopératoire de l’anesthésie. I – Construction et validation. Ann Fr Anesth Reanim 1999; 18: 848–857.
  11. Labarère J, François P, Auquier P et al. Development of a French inpatient satisfaction questionnaire. Int J Qual Health Care 2001; 13: 99–108.
  12. Scott A, Smith RD. Keeping the customer satisfied: issues in the interpretation and use of patient satisfaction surveys. Int J Qual Health Care 1994; 6: 353–359
  13. Vrijkotte et al. Effects of Work Stress on Ambulatory Blood Pressure, Heart Rate, and Heart Rate Variability. Hypertension: Journal of the American Heart Association. 35: 880-886 (2000).


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  1. Dr. Valluri Ramarao
    Posted Jul 2015 at 4:34 am | Permalink

    In addition. to the cost involved, survey basically does not Support patient satisfaction. This need further support with other parameters.

  2. Terver Zua Tule
    Posted Sep 2015 at 7:44 am | Permalink


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