What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement

Good therapeutic connections and patient psychological safety: A qualitative survey study

BACKGROUND

Therapeutic connections (TCs) between patients and care providers are important for achieving desired patient outcomes. For patients, TC is associated with greater health self-efficacy, better health status, mental health status, and higher satisfaction with providers.

PURPOSE

The aim of the study was to examine patients' descriptions of what signals to them they have a TC with their care provider.

METHODOLOGY

We conducted an online survey of patients with a recent health care visit (n = 1,766). This study analyzed the results of an open-ended question that asked how patients know they have a good TC with their care provider. Data were analyzed using framework analysis to determine the extent to which patient responses indicated TC dimensions. A thematic content analysis identified emergent themes.

RESULTS

Of the TC dimensions, words associated with Shared Deliberation were mentioned by 60% of respondents. Other dimension mentions ranged between 14% (Shared Mind) and 2% (Bond). Thematic content analysis revealed that patient psychological safety seems to be required for many patients to feel connected.

CONCLUSION

A majority of patients indicated that good TCs happen when they feel seen and heard by providers. However, it appears that prior to feeling a strong TC, patients need to feel safe to be fully welcome into the encounter.

PRACTICE IMPLICATIONS

Health care organizations need to give care providers the uninterrupted time and space they need to fully connect with patients. Training about how to create a psychologically safe environment for patients should be tailored for practicing providers, leaders, and students in health care fields.

What matters to you? An observational field study of patient and care provider expectations for health care relationships

Therapeutic connections (TC) between patients and providers are foundational to patient-centered care, which is co-produced between patients and care providers. This necessitates that we understand what patients expect from TCs, the extent to which providers know what patients expect, and what providers expect. The purpose of this study was to examine nine TC dimensions and determine which are most important to patients, which dimensions providers believe are most important to patients, and which are most important to providers. An online survey of patients (n = 388) and care providers (n = 433) was conducted in the USA in March 2021. Respondents rated the extent to which the nine TC dimensions were important to them, followed by open-ended questions to expand upon what matters. The quantitative responses were rank-ordered and rankings were compared across groups. All groups ranked "having the patient's best interest in mind no matter what" as the top expectation. Patients also ranked "caring commitment" and being "on the same page" as highly important. Providers were relatively accurate in ranking what they believed was most important to patients. Respondents affirmed the TC dimensions in the qualitative results, adding nuance and context, such as patients feeling "heard" and noting providers that go "above and beyond." Providers ranked dimensions differently for themselves, prioritizing "full presence" and "emotional support" of patients. This study is among the first to examine expectations for TC. TC could play an explanatory role in understanding variation in patient experience ratings and other outcomes.

Experiences of living kidney donors: A synthesis of unsolicited patient narratives

INTRODUCTION

Despite the lauded benefits of living kidney donation, there is growing evidence of the challenges that living kidney donors (LKD) encounter in their donation trajectory and gaps in healthcare service provision. However, most of the evidence is derived from research conducted by clinicians or academic investigators. Significantly less attention has been devoted to analyzing unsolicited accounts of LKDs' experiences.

METHODS

We conducted a review and synthesis of published unsolicited first-person narratives of LKDs and aimed to synthesize their experiences and identify care needs. Four electronic databases were searched and 27 LKD narratives were included in our final analysis. Thematic synthesis was used to generate themes inductively.

RESULTS

Although the majority of LKDs reported the act of donation to be a fulfilling experience, almost 48% reported encountering challenges in the care that they received. Also, 29% of LKDs reported experiencing an adverse clinical event. Five distinct themes emerged surrounding the donation experience and healthcare needs: 1) Educational needs due to perceived lack of transparency and compensating for knowledge gaps; 2) Respect for donor autonomy due to coercive influences from family or healthcare providers, lack of respect for donor preferences and loopholes in the consent process; 3) Unmet care needs related to poor communication with healthcare providers, coordination issues and inconsistent and inadequate long-term care; 4) Unanticipated outcomes due to economic costs and the emotional burden of donation; and 5) Contributing beyond the donation event by advocating for a balanced view of donation and generating support mechanisms.

CONCLUSION

In this synthesis of LKDs narratives, important care gaps and the need to advocate for a balanced perspective on living kidney donation were highlighted. Our review underscores the value of patients' own stories as critical evidence that can inform improvement in healthcare service delivery.

"Nothing Is More Powerful than Words:" How Patient Experience Narratives Enable Improvement

BACKGROUND AND OBJECTIVES

Patient experience narratives (narratives) are an increasingly important element of both measurement approaches and improvement efforts in healthcare. Prior studies show that narratives are considered by both clinicians and staff to be an appealing, meaningful, and credible form of evidence on performance. They also suggest that making concrete use of narratives within organizational settings to improve care can be complex and challenging. Our qualitative study was designed to explore how middle managers working in a health system's outpatient clinics value and use written narratives in their day-to-day work.

METHODS

We conducted qualitative interviews with 20 middle managers working in 8 outpatient clinics. Interviews were fully transcribed, loaded into MAX-QDA software, and coded using thematic analysis techniques. Code reports were extracted and reanalyzed for subthemes related to the objectives of this paper.

RESULTS

Middle managers across sites described valuing narratives as a tool to: enable better patient experience assessment by augmenting data from patient experience scores; deepen understanding of and relationships with patients; provide insight about operational issues; identify areas for needed improvement and potential solutions; and facilitate strategic work. They reported using narratives for a range of activities related to their roles as supervisors, such as focusing attention on positive practices and needed improvements, promoting deeper group learning, motivating change, reinforcing sense of purpose for staff, recognizing staff strengths and training needs, and inspiring transformational thinking. Finally, interviewees reported numerous specific quality improvement projects (both short- and longer-term) that were informed by narratives-for example, by identifying an issue to be addressed or by suggesting a workable solution. Together, these interviews suggest a collective "narrative about narratives" woven by these organizational actors-a story which illustrates how narratives are highly relevant for how middle managers derive meaning from their work, put organizational values such as responsive service provision into practice, and enact their roles as supervisors.

CONCLUSIONS

Our results add to the nascent literature a detailed description of how narratives can be used both as a tool for middle managers in their leadership and supervisory roles, and as a blueprint for improvement work within outpatient settings. They also illuminate why patient experience scores may improve when narrative data are collected and used. Finally, our results suggest that for middle managers, perhaps "nothing is more powerful than words" because narratives function as both an insight provider and a compelling tool that adds direction and meaning to workplace endeavors.

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy

OBJECTIVE

To improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).

METHODS

A quality improvement initiative was implemented at a large academic medical centre in the USA for postpartum individuals with HDP. The primary aim was to increase completed BP checks within 7 days of hospital discharge from 40% to 70% in people with HDP in 6 months. Secondary aims included improving rates of scheduled visits, completed visits within 3 days for severe HDP and unattended visits. The balancing measure was readmission rate. Statistical process control charts were used, and data were stratified by race and ethnicity. Direct feedback from birthing individuals was obtained through phone interviews with a focus on black birthing people after a racial disparity was noted in unattended visits.

RESULTS

Statistically significant improvements were noted across all measures. Completed and scheduled visits within 7 days of discharge improved from 40% to 76% and 61% to 90%, respectively. Completed visits within 3 days for individuals with severe HDP improved from 9% to 49%. The unattended visit rate was 26% at baseline with non-Hispanic black individuals 2.3 times more likely to experience an unattended visit than non-Hispanic white counterparts. The unattended visit rate decreased to 15% overall with an elimination of disparity. A need for BP devices at discharge and enhanced education for black individuals was identified through patient feedback.

CONCLUSION

Timely follow-up of postpartum individuals with HDP is challenging and requires modification to our care delivery. A hospital-level quality improvement initiative using birthing individual and frontline feedback is illustrated to improve equitable, person-centred care.

Narrative comments about pediatric inpatient experiences yield substantial information beyond answers to closed-ended CAHPS survey questions

PURPOSE

Adults' comments on patient experience surveys explain variation in provider ratings, with negative comments providing more actionable information than positive comments. We investigate if narrative comments on the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey of inpatient pediatric care (Child HCAHPS) account for global perceptions of the hospital beyond that explained by reports about specific aspects of care.

METHODS

We analyzed 545 comments from 927 Child HCAHPS surveys completed by parents and guardians of hospitalized children with at least a 24-h hospital stay from July 2017 to December 2020 at an urban children's hospital. Comments were coded for valence (positive/negative/mixed) and actionability and used to predict Overall Hospital Rating and Willingness to Recommend the Hospital along with Child HCAHPS composite scores.

RESULTS

Comments were provided more often by White and more educated respondents. Negative comments and greater actionability of comments were significantly associated with Child HCAHPS global rating measures, controlling for responses to closed-ended questions, and child and respondent characteristics. Each explained an additional 8% of the variance in respondents' overall hospital ratings and an additional 5% in their willingness to recommend the hospital.

CONCLUSIONS

Child HCAHPS narrative comment data provide significant additional information about what is important to parents and guardians during inpatient pediatric care beyond closed-ended composites.

PRACTICE IMPLICATIONS

Quality improvement efforts should include a review of narrative comments alongside closed-ended responses to help identify ways to improve inpatient care experiences. To promote health equity, comments should be encouraged for racial-and-ethnic minority patients and those with less educational attainment.

Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

How Stories Can Contribute Toward Quality Improvement in Long-Term Care

It is important to evaluate how residents, their significant others, and professional caregivers experience life in a nursing home to improve quality of care based on their needs and wishes. Narratives are a promising method to assess this experienced quality of care as they enable a rich understanding, reflection, and learning. In the Netherlands, narratives are becoming a more substantial element within the quality improvement cycle of nursing homes. The added value of using narrative methods is that they provide space to share experiences, identify dilemmas in care provision, and provide rich information for quality improvements. The use of narratives in practice, however, can also be challenging as this requires effective guidance on how to learn from this data, incorporation of the narrative method in the organizational structure, and national recognition that narrative data can also be used for accountability. In this article, 5 Dutch research institutes reflect on the importance, value, and challenges of using narratives in nursing homes.

Leveraging Patients' Creative Ideas for Innovation in Health Care

Policy Points Patients' creative ideas may inform learning and innovation that improve patient-centered care. Routinely collected patient experience surveys provide an opportunity to invite patients to share their creative ideas for improvement. We develop and assess a methodological strategy that validates question wording designed to elicit creative ideas from patients. Health care organizations should consider how to report and use these data in health care delivery and quality improvement, and policymakers should consider promoting the use of narrative feedback to better understand and respond to patients' experiences.

CONTEXT

Learning health systems (LHSs) have been promoted for a decade to achieve high-quality, patient-centered health care. Innovation driven by knowledge generated through day-to-day health care delivery, including patient insights, is critical to LHSs. However, the pace of translating patient insights into innovation is slow and effectiveness inadequate. This study aims to evaluate a method for systematically eliciting patients' creative ideas, examine the value of such ideas as a source of insight, and examine patients' creative ideas regarding how their experiences could be improved within the context of their own health systems.

METHODS

The first stage of the study developed a survey and tested strategies for elicitation of patients' creative ideas with 600 patients from New York State. The second stage deployed the survey with the most generative open-ended question sequence within a health care system and involved analysis of 1,892 patients' responses, including 2,948 creative ideas.

FINDINGS

Actionable, creative feedback was fostered by incorporating a request for transformative feedback into a sequence of narrative elicitation questions. Patients generate more actionable and creative ideas when explicitly invited to share such ideas, especially patients with negative health care experiences, those from minority racial/ethnic backgrounds, and those with chronic illness. The most frequently elicited creative ideas focused on solving challenges, proposing interventions, amplifying exceptional practices, and conveying hopes for the future.

CONCLUSIONS

A valid and reliable method for eliciting creative ideas from patients can be deployed as part of routine patient experience surveys that include closed-ended survey items and open-ended narrative items in which patients share their experiences in their own words. The elicited creative ideas are promising for patient engagement and innovation efforts. This study highlights the benefits of engaging patients for quality improvement, offers a rigorously tested method for cultivating innovation using patient-generated knowledge, and outlines how creative ideas can enable organizational learning and innovation.

Learning from patients: The impact of using patients' narratives on patient experience scores

BACKGROUND

Enthusiasm has grown about using patients' narratives-stories about care experiences in patients' own words-to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published.

PURPOSE

We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores.

APPROACH

We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources.

RESULTS

Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge ( p < .01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient-provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff.

CONCLUSION

Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge.

PRACTICE IMPLICATIONS

Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains.

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

How exposure to patient narratives affects stereotyped choices of primary care clinicians

In this paper, we examine whether patient narratives alter the impact of stereotyping on choice of primary care clinicians: in this case, the common presumption that female doctors will be more attentive to empathic relationships with patients. 1052 individuals were selected from a nationally representative Internet panel to participate in a survey experiment. Participants were given performance data about 12 fictitious primary care physicians, including a randomized set of narrative feedback from patients. We compared the choice of clinician made by participants who value bedside manner and were exposed to narratives in the experiment, compared to those valuing bedside manner who had not had this exposure. We estimated multivariate logistic regressions to assess whether exposure to patient comments that "disrupt" stereotypes influenced choice of physicians. Participants who saw patient comments and had previously reported caring about bedside manner had a 67% higher odds of choosing a female physician than those participants that did not see a patient comments, controlling for the content of the narratives themselves. When participants were exposed to patient comments that disrupt gendered stereotypes, they had a 40% lower odds of choosing a female physician. Simple exposure to patient narratives that do not clearly disrupt gendered stereotypes increased the likelihood of choosing a female clinician by priming attention to relational aspects of care. However, when the content of a sufficient proportion of patient comments runs counter stereotypes, even a minority of narratives is sufficient to disrupt gendered-expectations and alter choices.

Not just surveys and indicators: narratives capture what really matters for health system strengthening

Health system strengthening remains elusive and challenging. Health systems in many countries in sub-Saharan Africa are frequently characterised as weak, with inadequate management and accountability mechanisms, and poor human and financial resources. Putting patients and staff at the heart of health systems is an essential step towards strengthening them. As one of the three pillars of quality in health care, understanding patient experiences is key to moving towards people-centred care. Yet patient experiences are not a singular concept. Patient narratives can convey individual experiences of illness and health care, which complement and augment epidemiological and public health evidence. These narratives, gathered with rigorous, interview-based research and shared with digital tools (audio and video), can generate persuasive evidence. This evidence has important potential for influencing policy and practice, and for supporting people-centred care, but has not been tested systematically in low-income countries. In the Kenyan context of newborn health, work under way is generating evidence to show the transformative potential of patient narratives.

What Patient-Experience Data Reveal about Trust

This essay analyzes two types of patient-experience data to broaden and deepen understanding of trust in health care. Analysis of patients' open-ended comments shows a close connection between patients' feelings of trust and their intent to recommend providers and provider organizations-a global measure to evaluate patients' perceptions of care experiences. Patients' comments also reveal the bidirectional building of trust between the patient and the caregiver. Trust gets built when patients perceive their caregivers to trust their knowledge of their bodies as well as when caregivers demonstrate caring behaviors that earn the patients' trust. Patients' ratings of a closed-ended survey item on "confidence in provider" create the greatest differentiation for the global measure of patient experience-whether patients did or did not recommend a practice or provider. The essay also discusses related findings on pre-visit friction and the use of humor by the caregiver to expand understanding of trust.

Patient Comments on the Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS) Survey Reflect Improvements in Provider Behaviors From Coaching

GOAL

Patient experience survey data are used to examine the patient-centeredness of care, identify areas for improvement, and monitor interventions aimed to enhance the patient experience. Most healthcare organizations measure patient experience using Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Studies have documented the use of CAHPS closed-ended survey responses for completing public reports, monitoring internal feedback and performance, identifying areas of improvement, and evaluating interventions to improve care. However, limited evidence exists on the utility of patients' comments on CAHPS surveys for evaluating provider-level interventions. To explore this potential, we examined comments on the CAHPS Clinician and Group (CG-CAHPS) 2.0 visit survey before and after a provider intervention. The "shadow coaching" intervention had been shown to improve provider performance and patient experience scores on the CG-CAHPS overall provider rating and provider communication composite.

METHODS

We examined how patient comments on the CG-CAHPS survey differed before and after shadow coaching of 74 providers. We described the valence (tone), content, and actionability of 1,935 comments-1,051 collected before coaching and 884 collected after coaching-to see how these aspects changed before and after providers were coached.

PRINCIPAL FINDINGS

Patient comments reflected improved CG-CAHPS scores after shadow coaching. The proportion of positive comments increased, and comments about doctors were more positive. Comments about time spent in the examination room decreased, apparently reflecting the decreased proportion of negative comments after coaching. Comments regarding three of the four aspects of provider communication asked on the CG-CAHPS survey were more positive after coaching (provider listens carefully, shows respect, spends enough time); the valence of comments about the fourth aspect (provider explains things in a way that is easy to understand) did not change. Also, comments describing an overall positive evaluation of the practice increased. Comments were generally less actionable after coaching, perhaps reflecting the increased positivity of the comments.

PRACTICAL APPLICATIONS

Patient comments collected before the provider intervention reflected overall improvements in provider behavior, as indicated by medium-to-large statistically significant improvements in CG-CAHPS composite scores. These results suggest that patient comments from the CG-CAHPS survey can be used as input for quality improvement or an evaluation of provider-level interventions. Tracking the valence and content of comments about providers before and after an intervention to improve care is a practical method to learn how provider behavior changes.

Social determinants of ambulatory care sensitive conditions: a qualitative meta-synthesis based on patient perspectives

Background

Hospitalizations or emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSC) are preventable but cost billions in modern countries. The objective of the study is to use a meta-synthesis approach based on patients' narratives from qualitative studies to reveal why individuals are at risk of ACSC hospitalizations or ED visits.

Methods

PubMed, Embase, Cochrane Library, and Web of Science databases were utilized to identify qualified qualitative studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis were used for reporting the review. The thematic synthesis was used to analyze the data.

Results

Among 324 qualified studies, nine qualitative studies comprising 167 unique individual patients were selected based on the inclusion/exclusion criteria. Through the meta-synthesis, we identified the core theme, four major themes, and the corresponding subthemes. Poor disease management, the core theme, turns individuals at risk of ACSC hospitalizations or ED visits. The four major themes contribute to poor disease management, including difficulties in approaching health services, non-compliance with medications, difficulties in managing the disease at home, and poor relationships with providers. Each major theme comprised 2-4 subthemes. The most cited subthemes are relative to upstream social determinants, such as financial constraints, inaccessible health care, low health literacy, psychosocial or cognitive constraints.

Conclusion

Without addressing upstream social determinants, socially vulnerable patients are unlikely to manage their disease well at home even though they know how to do it and are willing to do it.

Trial registration

National Library of Medicine, with ClinicalTrials.gov, Identifier: NCT05456906. https://clinicaltrials.gov/ct2/show/NCT05456906.

Evaluation of a protocol for eliciting narrative accounts of pediatric inpatient experiences of care

OBJECTIVE

To evaluate the measurement properties of a set of six items designed to elicit narrative accounts of pediatric inpatient experience.

DATA SOURCES

Data came from 163 participants recruited from a probability-based online panel of U.S. adults. Participants were family members of a child who had an overnight hospital stay in the past 12 months.

STUDY DESIGN

Cross-sectional survey with follow-up phone interviews.

DATA COLLECTION/EXTRACTION METHODS

Participants completed an online (n = 129) or phone (n = 34) survey about their child's hospitalization experience. The survey contained closed-ended items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey, followed by the six narrative items. Approximately 2 weeks after completing the survey, 47 participants additionally completed a one-hour, semi-structured phone interview, the results of which served as a "gold standard" for evaluating the fidelity of narrative responses. Qualitative content analysis was used to code narrative and interview responses for domains of patient experience and actionability.

PRINCIPAL FINDINGS

The average narrative was 248 words (SD = 319). Seventy-nine percent of narratives mentioned a topic included in the Child HCAHPS survey; 89% mentioned a topic not covered by that survey; and 75% included at least one detailed description of an actionable event. Overall, there was 66% correspondence between narrative and interview responses. Correspondence was higher on the phone than in the online condition (75% vs. 59%).

CONCLUSIONS

Narratives elicited from rigorously designed multi-item sets can provide detailed, substantive information about pediatric inpatient experiences that hospitals could use to improve child and family experiences during pediatric hospitalization. They add context to closed-ended survey item responses and provide information about experiences of care important to children and families that are not included in quantitative surveys.

Parents Have More to Say: Comments From the Child HCAHPS Single Question Versus a Narrative Item Set

BACKGROUND AND OBJECTIVES

Narrative comments from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey from a single open-ended question are specific enough to make improvements (ie, actionable). A multiitem set might yield more insights. We compare comments from the single-item Child Hospital CAHPS and the 6-item beta version Narrative Item Set (NIS).

METHODS

The Child HCAHPS NIS was piloted 2021 to 2022 at an urban children's hospital that fielded the Child HCAHPS survey since 2017. We analyzed 382 NIS comments (n = 77 parents and guardians) and compared them to single-item comments.

RESULTS

NIS respondents wrote nearly 6 times the word count compared with respondents presented with a single item, with 75% of NIS respondents providing narrative to 5 or 6 NIS items. Single-item comments were more positive (57% vs 39% NIS), yet most (61%) NIS comments included at least 1 negative remark (vs 43% single-item). Eighty-two percent of NIS comments included content on the Child HCAHPS survey (vs 51% single-item). The most common Child HCAHPS topics in NIS narratives were about being kept informed of child's care and whether doctors treated respondents with courtesy and respect. More NIS comments were deemed actionable (69% vs 39% single-item), with 1 NIS item - what a parent wished had gone differently- eliciting the most-actionable narrative.

CONCLUSIONS

The multi-item NIS elicited high percentages of comments with sufficient detail to make improvements. A large NIS demonstration is needed to assess how quality leaders and frontline staff use NIS comments to improve inpatient pediatric care.

Exploring the Impact of Storytelling for Hospitalized Patients Recovering from COVID-19

There are mental and physical deficits associated with COVID-19 infection, particularly among individuals requiring hospitalization. Storytelling is a relational intervention that has been used to help patients make sense of their illness experiences and to share their experiences with others, including other patients, families and healthcare providers. Relational interventions strive to create positive, healing stories versus negative ones. In one urban acute care hospital, an initiative called the Patient Stories Project (PSP) uses storytelling as a relational intervention to promote patient healing, including the development of healthier relationships among themselves, with families and with healthcare providers. This qualitative study employed a series of interview questions that were collaboratively developed with patient partners and COVID-19 survivors. The questions asked consenting COVID-19 survivors about why they chose to tell their stories and to flesh out more about their recovery process. Thematic analyses of six participant interviews resulted in the identification of key themes along a COVID-19 recovery pathway. Patients' stories revealed how survivors progress from being overwhelmed by their symptoms to making sense of what is happening to them, providing feedback to their care providers, feeling gratitude for care received, becoming aware of a new state of normal, regaining control of their lives, and ultimately discovering meaning and an important lesson behind their illness experience. Our study's findings suggest that the PSP storytelling approach holds potential as a relational intervention to support COVID-19 survivors along a recovery journey. This study also adds knowledge about survivors beyond the first few months of recovery.

The use of patient experience feedback in rehabilitation quality improvement and codesign activities: Scoping review of the literature

Objective

To characterize the literature, reported enablers, and gaps on the use of patient experience feedback for person-centered rehabilitation quality improvement and codesign activities.

Design

Scoping Review.

Data sources

Scientific databases (PubMed, CINAHL, Rehabdata, Scopus, Web of Science, ProQuest), website searches (e.g. Beryl Institute), snowballing, and key-informant recommendations.

Methods

Two independent reviewers performed title and abstract screenings and full-text reviews. Eligibility focused on English-language, peer-reviewed (all time) and gray literature (last five years) that used patient experience feedback in rehabilitation improvement activities. The aims, settings, methods, findings, implications, and reported limitations were extracted, followed by content analyses identifying reported enablers and gaps.

Results

Among the 901 unique references and 52 full texts reviewed, ten were included: four used patient experience surveys for improving patient experiences; six used codesign methodologies to engage patient feedback in service improvement activities. Implementation enablers included securing managerial support, having a structured methodology and facilitator, using efficient processes, engaging staff experiences, and using appreciative inquiry. Reported study gaps included limited follow-up, low sample sizes, analytical limitations, lack of reported limitations, or narrow range of perspectives (e.g. not from people with severe impairments).

Conclusion

Few examples of the use of patient experience feedback in quality improvement or codesign activities were found in the rehabilitation literature. Patient experience improvement activities relied exclusively on retrospective survey data, which were not combined with often more actionable forms (e.g. qualitative, real time) of patient experience feedback. Further research might consider design of activities that collect and use patient experience feedback for rehabilitation service improvements.

Summary of the 2020 AHRQ research meeting on 'advancing methods of implementing and evaluating patient experience improvement using consumer assessment of healthcare providers and systems (CAHPS®) surveys'

BACKGROUND

The Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts.

TOPICS COVERED.

Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience?

KEY THEMES

Providers and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.

Reframing Patient Experience Approaches and Methods to Achieve Patient-Centeredness in Healthcare: Scoping Review

(1) There has been growing attention among healthcare researchers on new and innovative methodologies for improving patient experience. This study reviewed the approaches and methods used in current patient experience research by applying the perspective of design thinking to discuss practical methodologies for a patient-centered approach and creative problem-solving. (2) A scoping review was performed to identify research trends in healthcare. A four-stage design thinking process (“Discover”, “Define”, “Develop”, and “Deliver”) and five themes (“User focus”, “Problem-framing”, “Visualization”, “Experimentation”, and “Diversity”), characterizing the concept, were used for the analysis framework. (3) After reviewing 67 studies, the current studies show that the iterative process of divergent and convergent thinking is lacking, which is a core concept of design thinking, and it is necessary to employ an integrative methodology to actively apply collaborative, multidisciplinary, and creative attributes for a specific and tangible solution. (4) For creative problem-solving to improve patient experience, we should explore the possibilities of various solutions by an iterative process of divergent and convergent thinking. A concrete and visualized solution should be sought through active user interactions from various fields. For this, a specific methodology that allows users to collaborate by applying the integrative viewpoint of design thinking should be introduced.

Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients

OBJECTIVE

Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool.

METHODS

We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients ≥13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression.

RESULTS

We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16).

CONCLUSIONS

We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.

What Parents have to Say: Content and Actionability of Narrative Comments from Child HCAHPS Survey

OBJECTIVE

To examine the content and actionability of written comments from parents and guardians on the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey.

METHODS

We coded 548 narrative text comments linked to demographic information from the Child HCAHPS survey from July 2017 to December 2020 about inpatient pediatric care at an urban children's hospital-within-a-hospital at an academic medical center. We developed initial codes based on research findings and the content of the Child HCAHPS survey, and also added codes that emerged from the comments. We performed directed and conventional content analysis.

RESULTS

Most comments were positive and provided by the child's mother. About half referred to content on the Child HCAHPS survey, primarily on being treated with courtesy and respect or explaining care at discharge. Comments about other topics most frequently provided a narrative rating of the provider or described whether providers were caring and friendly. Thirty-nine percent of comments were deemed sufficiently specific to make improvements (ie, actionable) in inpatient pediatric care; negative comments or comments about care for sicker patients were more often actionable.

CONCLUSIONS

Child HCAHPS comments provided rich detail and a large portion were deemed actionable. Comments also provided insights into topics both on the survey itself and on many other inpatient pediatric issues raised by parents and guardians. More research is needed on the value of Child HCAHPS comments, the association between Child HCAHPS open-ended and closed-ended responses, and how quality leaders and frontline staff use comments to improve inpatient pediatric care.

Content and Actionability of Recommendations to Providers After Shadow Coaching

BACKGROUND AND OBJECTIVES

Health care organizations track patient experience data, identify areas of improvement, monitor provider performance, and assist providers in improving their interactions with patients. Some practices use one-on-one provider counseling ("shadow coaching") to identify and modify provider behaviors. A recent evaluation of a large shadow coaching program found statistically significant improvements in coached providers' patient experience scores immediately after being coached. This study aimed to examine the content of the recommendations given to those providers aimed at improving provider-patient interactions, characterize these recommendations, and examine their actionability.

METHODS

Providers at a large, urban federally qualified health center were selected for coaching based on Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) patient experience scores (92 of 320 providers), shadowed by a trained peer coach for a half to full day and received recommendations on how to improve interactions with their patients. We coded 1082 recommendations found in the 92 coaching reports.

RESULTS

Reports contained an average of 12 recommendations. About half encouraged consistency of existing behaviors and half encouraged new behaviors. Most recommendations related to behaviors of the provider rather than support staff and targeted actions within the examination room rather than other spaces (eg, waiting room). The most common recommendations mapped to behavioral aspects of provider communication. Most recommendations targeted verbal rather than nonverbal communication behaviors. Most recommendations were actionable (ie, specific, descriptive), with recommendations that encouraged new behaviors being more actionable than those that encouraged existing actions.

CONCLUSIONS

Patient experience surveys are effective at identifying where improvement is needed but are not always informative enough to instruct providers on how to modify and improve their interactions with patients. Analyzing the feedback given to coached providers as part of an effective shadow-coaching program provides details about implementation on shadow-coaching feedback. Recommendations to providers aimed at improving their interactions with patients need to not only suggest the exact behaviors defined within patient experience survey items but also include recommended behaviors indirectly associated with those measured behaviors. Attention needs to be paid to supplementing patient experience data with explicit, tangible, and descriptive (ie, actionable) recommendations associated with the targeted, measured behaviors. Research is needed to understand how recommendations are put into practice by providers and what motivates and supports them to sustain changed behaviors.

Benefits and harms of patient stories on social media from the perspective of healthcare providers and administrators in Ontario

There has been a growing use of social media by patients to share their healthcare experiences and produce information that can be helpful to other patients seeking healthcare services. These stories can reveal issues in healthcare quality. However, faced with the inherent risks of social media, healthcare providers have been skeptical about the value of these stories, and many healthcare systems have adopted restrictive and protective policies to control the use of social media by healthcare providers. This study explores healthcare providers' and administrators' perspectives on patient stories on social media and whether they can use the stories to evaluate healthcare experiences. Semi-structured interviews (n = 21) were conducted with healthcare providers and administrators, including physicians, nurses, and quality managers in Ontario, Canada, between April 2018 and May 2019. Inductive and data-driven thematic analysis was used to analyze the data. Several barriers prevent healthcare providers from realizing the benefits of social media, including concerns about the quality of patients' feedback, the professional codes of conduct, and the time and effort required to process these stories. The study findings suggest that cultural changes in the healthcare system might be required to foster the use of social media for healthcare quality improvement and enable the development of a safe patient-provider communication environment that facilitates the exchange of constructive feedback between the two parties without the fear of legal consequences, breaches of patient privacy, or violation of professional codes of conduct.

[Satisfaction of Rehabilitation Patients on Social Media Websites and Online Rating Portals]

PURPOSE

Patients increasingly express themselves about their medical rehabilitation stay, evaluate health service providers with star ratings, and write reviews on the internet. So far, no results are available regarding online patient satisfaction for inpatient medical rehabilitation in Germany. For the first time, this study conducted a systematic analysis of rehabilitation patient satisfaction on social media websites and hospital rating portals.

METHODS

We collected reviews of medical rehabilitation on the portal Klinikbewertungen.de and the social network Facebook for 8 indication groups (orthopedics, psychosomatics/psychotherapy, oncology, cardiology, neurology, internal medicine, pulmonology/dermatology, gastroenterology) with a full data extraction over 3 survey years (October 2014-September 2017) and for rehabilitation clinics with main bed occupancy of retirement insurance (N=497). The star ratings, aggregated according to indication groups, were evaluated to determine patient satisfaction (Pearson's chi-square test, Fisher's exact test, Phi coefficient).

RESULTS

A total of 97.2% of the rehabilitation clinics were represented, with 24,806 ratings on Klinikbewertungen.de. The most frequently evaluated indication groups were orthopedics (38.5%) and psychosomatics/psychotherapy (27.1%). Facebook ratings (N=4,127) were collected for rehabilitation clinics with one department (38.6%) in order to ensure an indication group assignment. Almost the same number of ratings were determined on official (48.7%) and unofficial Facebook pages (51.3%), with no significant correlation between website management and overall satisfaction (p>0.05). On the Facebook pages of the rehabilitation clinics, 49.1% of the ratings were written by women (38.5% by men; 12.4% not assignable). Sociodemographic information on Klinikbewertungen.de was based solely on the status of the insured (89.1% of those with statutory insurance). Overall, 95.4% of the reviews were written by patients and 4.0% by relatives, with 77.5% of patients recommending the clinic to other users (relatives: 37.2%). Most patient ratings were positive. However, there were differences in overall satisfaction between the indication groups. Patients in oncology (77.9%) were more satisfied than those in neurology (59.0%).

CONCLUSIONS

Online ratings of inpatient medical rehabilitation were collected to a considerable extent. These were mostly positive. The results are comparable to standardized surveys. Despite restrictions in the use of social media data, the results indicated that the publicly available real-time online feedback from patients can provide useful information for the quality management of clinics as well as for patients in exercising their right to choose a rehabilitation clinic.

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care

BACKGROUND

Patients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician's view. We aimed to develop a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning.

METHOD

A multi-stakeholder advisory group including patients, families, clinicians, and experts in diagnostic error, patient engagement and safety, and user-centred design, co-developed a framework for PRDBs in ambulatory care. We tested the framework using standard qualitative analysis methods with two physicians and one patient coder, analysing 2165 patient-reported ambulatory errors in two large surveys representing 25 425 US respondents. We tested intercoder reliability of breakdown categorisation using the Gwet's AC1 and Cohen's kappa statistic. We considered agreement coefficients 0.61-0.8=good agreement and 0.81-1.00=excellent agreement.

RESULTS

The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The frequency of PRDBs was 6.4% in one dataset and 6.9% in the other. Intercoder reliability showed good-to-excellent reliability in each dataset: AC1 0.89 (95% CI 0.89 to 0.90) to 0.96 (95% CI 0.95 to 0.97); kappa 0.64 (95% CI 0.62, to 0.66) to 0.85 (95% CI 0.83 to 0.88).

CONCLUSIONS

The PRDB framework, developed in partnership with patients/families, can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.

Patient-reported Outcome Measures - A Call for More Narrative Evidence

This article puts forward the need to reconsider the current underlying quantitative approach underpinning the application of patient reported outcomes, to a mixed methods approach through the tandem use of patients’ narrative that enables informants in addition to their scores to express the reality of the ways in which their lives are physically and mentally impacted by their health status.

Incorporating Patient Narratives to Enhance Audiological Care and Clinical Research Outcomes

Purpose The engagement of patients as key stakeholders in their experience of care processes is a critical component of quality improvement efforts for both clinical care and translational research. Increasingly, health care systems are soliciting input from patients on care processes and experiences through surveys, patient interviews, and patient video narratives. The purpose of this viewpoint article is twofold: (a) to describe the increasing role of patient narratives about their experiences with adverse health conditions to inform patient-centered research and quality improvement efforts and (b) to present three patient narratives that highlight the real-world impacts of hearing loss and tinnitus, the life enhancing impacts of aural rehabilitation, and the importance of prospective ototoxicity monitoring in individuals with complex health conditions. Conclusion Patient narratives provide individual patient perspectives that can be used to build awareness of the range of experiences and impact of hearing disorders, and to explore patient preferences for when and how to implement hearing-related clinical services.

The Story as a Quality Instrument: Developing an Instrument for Quality Improvement Based on Narratives of Older Adults Receiving Long-Term Care

The individual experiences of older adults in long-term care are broadly recognized as an important source of information for measuring wellbeing and quality of care. Narrative research is a special type of qualitative research to elicit people’s individual, diverse experiences in the context of their lifeworld. Narratives are potentially useful for long-term care improvement as they can provide a rich description of an older adult’s life from their own point of view, including the provided care. Little is known about how narratives can best be collected and used to stimulate learning and quality improvement in long-term care for older adults. The current study takes a theoretical approach to developing a narrative quality instrument for care practice in order to discover the experiences of older adults receiving long-term care. The new narrative quality instrument is based on the available literature describing narrative research methodology. The instrument is deemed promising for practice, as it allows care professionals to collect narratives among older adults in a thorough manner for team reflection in order to improve the quality of care. In the future, the feasibility and usability of the instrument will have to be empirically tested.

[Positive association between successful rehabilitation and patient hospital ratings: Experience reports of patients in rehabilitation on a hospital rating and review site]

INTRODUCTION

Feedback from patients about aspects of rehabilitation services is increasingly provided online, for example, on specialized hospital comparison websites. Therefore, we examined which kind of online statements from rehabilitation patients published on the leading hospital comparison website "Klinikbewertungen.de" (KB) is associated with a positive recommendation of a rehabilitation clinic and which negative aspects are associated with a non-recommendation.

METHODS

For eight indication groups stratified online statements of rehabilitants at KB were evaluated qualitatively using content analysis. The relationship between positive (negative) statements and the (non-) recommendation was examined.

RESULTS

Content analysis of 911 experience reports revealed 20 categories. Most often, it was the "rehabilitation success" perceived by rehabilitation patients that was significantly associated with a recommendation or a non-recommendation of a hospital, and in five quality assurance (QA) comparison groups the category "catering" was associated with a positive or negative recommendation. In all QS comparison groups, there was an association with at least one of the following process-oriented rehabilitation categories: "rehabilitation measures", "rehabilitation plan and rehabilitation goals" and / or "diagnosis to discharge".

DISCUSSION AND CONCLUSION

Patient experiences with the perceived "rehabilitation success" and with the central processes of rehabilitation are particularly important for the recommendation or non-recommendation of a hospital for patients in all eight indication groups. On the basis of these results, rehabilitation hospitals can specifically identify the aspects of care that are important when patients recommend a hospital for rehabilitation. Online narratives of patients provide additional insights into the reasons for patients' satisfaction or dissatisfaction with their rehabilitation. These narratives are available to potential rehabilitation patients as a low-threshold source of information and decision-making aid.

Integration of patient and clinician narratives into systematic reviews: An applied proof of concept

Health systems currently underutilize systematic reviews. Here, we describe a proof of concept project designed to augment the standard systematic review process by presenting qualitative information as a companion to a review on deprescribing interventions. We conducted a thematic analysis of semi-structured interviews with Veterans Health Administration clinicians and Veterans to describe first-hand experiences of engaging in the deprescribing process. Qualitative findings were incorporated into an interactive, web-based product designed to supplement the systematic review report. Preliminary evaluation suggests that integration of narratives as a companion to systematic reviews is of interest to frontline clinicians, researchers, and health system administrators.

Cultural conceptions of Women's labor pain and labor pain management: A mixed-method analysis

AIM

We assess American cultural beliefs about labor pain and labor pain management, including stereotypical and disparate beliefs about labor pain of women from different racial groups.

RATIONALE

Understanding cultural beliefs about labor pain is critical as these beliefs influence experience, interpretation, and treatment of labor pain.

METHOD

We used an online survey with quantitative and qualitative questions about American labor pain beliefs. Participants were recruited and compensated using TurkPrime's Panels during the first week in August 2017 and the last week in May 2018. The completion rate was 76.86 percent (n = 214). After screening using quality control items, the final sample included 200 respondents.

RESULTS

Qualitative results indicate that 56.5 percent (n = 113) of respondents have an accurate understanding of nociceptive/sensory drivers of labor pain, and 55.8 percent (n = 63) of those respondents focused on the second stage of labor. However, only two respondents (1%) mentioned non-sensory (i.e., psychological) causes of labor pain - reflecting a lack of cultural knowledge of the biopsychosocial nature of pain. Categorical responses indicate almost all respondents (95%; n = 190) believe women have a right to labor pain relief, and the majority believe labor pain has value (68%; n = 136) and should be treated medically (87%; n = 174). Quantitative results document stereotypical beliefs that women of color experience less labor pain than white women. Belief that there is value in experiencing labor pain and that pain should not be treated medically were both associated with greater racial disparities in beliefs about labor pain severity. Beliefs were not related to respondent sociodemographic identity, suggesting they are American cultural constructs.

CONCLUSION

Future consideration of the influence of dominant American cultural beliefs about labor pain - including misunderstanding of the nature of labor pain and racial bias in expectations of labor pain - on individuals, norms, and structures is expected to improve quality of patient care.