Using public reports of patient satisfaction for hospital quality improvement

Patient satisfaction and their determinants in outpatient department of a tertiary public hospital in Nepal: a cross-sectional study

BACKGROUND

Patient satisfaction is a vital metric for assessing healthcare quality and delivering patient-centered care. It can predict service utilization patterns by determining healthcare users' contentment with their providers. Consequently, evaluating patient satisfaction and its underlying factors is crucial to maintaining the quality of healthcare services. The present study aimed to assess patient satisfaction and its determinants in a tertiary care public hospital in Nepal. In this research, a cross-sectional design was employed to examine patient satisfaction within the Outpatient Department of Mental Hospital Lagankhel, Nepal. The study adopted a systematic random sampling approach for respondent selection, and stringent measures were implemented to uphold the validity and reliability of the collected data. To assess patient satisfaction comprehensively, the Patient Satisfaction Questionnaire-III (PSQ-III), developed by the RAND Corporation, was employed in conjunction with relevant sociodemographic variables. Utilizing mean scores and percentages, we calculated satisfaction levels across various dimensions. Additionally, a multinomial logistic regression analysis was conducted to investigate the relationships between patient satisfaction dimensions and sociodemographic characteristics.

RESULTS

This study encompassed perspective of 206 participants, with 57.3% representing patient relatives and 51% being male, median age of 32 years (standard deviation: 12.53). Notably, patients reported higher levels of satisfaction, particularly within the interpersonal relationship dimension, while the technical quality domain received comparatively lower satisfaction ratings. Multinomial logistic regression analysis underscored the significance of sociodemographic factors in shaping patient satisfaction, with age (p = 0.008), type of residence (p = 0.001), occupation (p = 0.0019), income status (p = 0.014), time to reach the healthcare facility (p = 0.013), and insurance enrollment status (p = 0.017) all demonstrating significant associations. These findings illuminate the intricate qualities of patient satisfaction within our healthcare context, offering actionable insights for enhancement and guiding the trajectory of future research endeavors.

CONCLUSIONS

Overall patient expressed satisfaction with service provided by tertiary care hospital, however continuous improvement remains essential. Conducting large-scale, nationwide studies across hospital tiers is vital. This data-driven approach empowers policymakers to allocate resources effectively, inform decision-making, and enact policies that exceed patient expectations, fostering a healthcare system of unparalleled excellence.

The uses of Patient Reported Experience Measures in health systems: A systematic narrative review

BACKGROUND

Many governments have programmes collecting and reporting patient experience data, captured through Patient Reported Experience Measures (PREMs). Our study aims to capture and describe all the ways in which PREM data are used within healthcare systems, and explore the impacts of using PREMs at one level (e.g. national health system strategy) on other levels (e.g. providers).

METHODS

We conducted a narrative review, underpinned by a systematic search of the literature.

RESULTS

1,711 unique entries were identified through the search process. After abstract screening, 142 articles were reviewed in full, resulting in 28 for final inclusion. A majority of papers describe uses of PREMs at the micro level, focussed on improving quality of front-line care. Meso-level uses were in quality-based financing or for performance improvement. Few macro-level uses were identified. We found limited evidence of the impact of meso‑ and macro- efforts to stimulate action to improve patient experience at the micro-level.

CONCLUSIONS

PREM data are used as performance information at all levels in health systems. The use of PREM data at macro- and meso‑ levels may have an effect in stimulating action at the micro-level, but there is a lack of systematic evidence, or evaluation of these micro-level actions. Longitudinal studies would help better understand how to improve patient experience, and interfaces between PREM scores and the wider associated positive outcomes.

Patient and healthcare provider perceptions on using patient-reported experience measures (PREMs) in routine clinical care: a systematic review of qualitative studies

BACKGROUND

Patient-reported experience measures (PREMs) assess quality-of-care from patients' perspectives. PREMs can be used to enhance patient-centered care and facilitate patient engagement in care. With increasing quality improvement studies in clinical practice, the use of PREMs has surged. As a result, knowledge about stakeholder experiences of using PREMs to assess quality of care across diverse clinical settings is needed to inform PREM implementation efforts. To address this, this review examines the qualitative literature on patient and healthcare provider experiences of using PREMs in clinical practice.

METHODS

Medline, Embase and PsycInfo were systematically searched from inception to May 2021. Additional searching of reference lists for all included articles and relevant review articles were performed. Retrieved articles were screened for eligibility by one reviewer and 25% cross-checked by a second reviewer across all stages of the review. Full texts meeting eligibility criteria were appraised against the COREQ checklist for quality assessment and thematic analysis was used to analyze textual data extracted from the results.

RESULTS

Electronic searches identified 2683 records, of which 20 studies met eligibility criteria. Extracted data were synthesized into six themes: facilitators to PREM implementation; barriers to PREM implementation; healthcare providers' perspectives towards using PREMs; patients' perspectives towards using PREMs; advantages of using PREMs in clinical practice; limitations and practical considerations to reduce resistance of PREM usage. The primary factors facilitating and impeding the use of PREMs include organizational-, staff- and patient-related factors.

CONCLUSION

Results can be used to guide the usage and implementation of PREMs in clinical settings by addressing the identified barriers and building on the perceived benefits to encourage adoption of PREMs. Results around facilitators to PREM implementation and practical considerations could also promote appropriate use of PREMs by healthcare providers, helping to improve practice and the quality of care based on patient feedback.

Understanding Patient Perceptions Towards Direct Primary Care: A Focus Group Study

Direct primary care (DPC) is a growing model of care that is suggested as an alternative to traditional fee-for-service healthcare. Patient-reported experiences of DPC can provide unique insight into the impact of joining the model and inform quality improvement. The purpose of this study was to investigate patient perceptions of DPC. Thirty-one participants were initially recruited for the study and completed a survey assessing patient demographics. Of the 31 participants, 10 went on to complete the focus group interviews. Qualitative analysis of focus group transcripts identified common themes and subthemes. Focus group findings were stratified into 4 themes including quality of care, access to care, affordability, physician qualities, and reasons for choosing DPC. The top positive subthemes were good communication, joining DPC due to poor past healthcare experiences, and physician personability. The most common negative subthemes were difficulty referring to specialists outside the practice, poor communication, and poor access to medications. All findings were presented and discussed with the investigated clinic to facilitate improvements in healthcare delivery.

Identifying factors that promote and limit the effective use of real-time patient experience feedback: a mixed-methods study in secondary care

OBJECTIVES

The Friends and Family Test (FFT) is commissioned by the National Health Service (NHS) in England to capture patient experience as a real-time feedback initiative for patient-centred quality improvement (QI). The aim of this study was to create a process map in order to identify the factors that promote and limit the effective use of FFT as a real-time feedback initiative for patient-centred QI.

SETTING

This study was conducted at a large London NHS Trust. Services include accident and emergency, inpatient, outpatient and maternity, which routinely collect FFT patient experience data.

PARTICIPANTS

Healthcare staff and key stakeholders involved in FFT.

INTERVENTIONS

Semi-structured interviews were conducted on 15 participants from a broad range of professional groups to evaluate their engagement with the FFT. Interview data were recorded, transcribed and analysed for using deductive thematic analysis.

RESULTS

Concerns related to inefficiency in the flow of FFT data, lack of time to analyse FFT reports (with emphasis on high level reporting rather than QI), insufficient access to FFT reports and limited training provided to understand FFT reports for frontline staff. The sheer volume of data received was not amenable to manual thematic analysis resulting in inability to acquire insight from the free text. This resulted in staff ambivalence towards FFT as a near real-time feedback initiative.

CONCLUSIONS

The results state that there is too much FFT free text for meaningful analysis, and the output is limited to the provision of sufficient capacity and resource to analyse the data, without consideration of other options, such as text analytics and amending the data collection tool.

Providers preferences towards greater patient health benefit is associated with higher quality of care

Standard theories of health provider behavior suggest that providers are motivated by both profit and an altruistic interest in patient health benefit. Detailed empirical data are seldom available to measure relative preferences between profit and patient health outcomes. Furthermore, it is difficult to empirically assess how these relative preferences affect quality of care. This study uses a unique dataset from rural Myanmar to assess heterogeneous preferences toward treatment efficacy relative to provider profit and the impact of these preferences on the quality of provider diagnosis and treatment. Using conjoint survey data from 187 providers, we estimated the marginal utilities of higher treatment efficacy and of higher profit, and the marginal rate of substitution between these outcomes. We also measured the quality of diagnosis and treatment for malaria among these providers using a previously validated observed patient simulation. There is substantial heterogeneity in providers' utility from treatment efficacy versus utility from higher profits. Higher marginal utility from treatment efficacy is positively associated with the quality of treatment among providers, and higher marginal utility from profit are negatively associated with quality of diagnosis. We found no consistent effect of the ratio of marginal utility of efficacy vs marginal utility of profit on quality of care. Our findings suggest that providers vary in their preferences towards profit and treatment efficacy, with those providers that place greater weight on treatment efficacy providing higher quality of care.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is 'good' in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability.

Examining the relationship between patient experience and readmission rates: A profile deviation analysis

The purpose of this study is to examine the relationship between patient experience and readmissions by exploring whether the deviation from an ideal patient-experience profile is linked to higher readmissions. Using patient experience scores, hospitals were assigned to one of four groups based on their deviation from an ideal profile. The readmission rates for the four groups were analyzed using Profile Deviation, ANOVA, and Least Significant Difference. Patient experience is a central component of hospital performance, specifically, readmission rates. Findings indicate as patient experience scores decrease, profile deviation increases, with a corresponding increase in readmission rate. This study provides empirical support for administrators focusing on patient experience as part of an overall strategy for reducing hospital readmissions. The key feature of this research is the use of a profile deviation methodology to examine the relationship between patient experience and readmission rates.

Six years of measuring patient experiences in Belgium: Limited improvement and lack of association with improvement strategies

OBJECTIVE

To examine trends in patient experiences in the period 2014-2019, describe improvement strategies implemented by hospitals in the same period, and study associations between patient experiences and implemented strategies.

DESIGN

Multi-center retrospective region-wide observational design.

SETTING

Flanders, Belgium.

PARTICIPANTS

44 out of 46 Flemish acute-care hospitals publicly reporting patient experiences via the Flemish Patient Survey (FPS).

MAIN OUTCOME MEASURE(S)

Primary outcomes were the two global FPS ratings: percentage of patients rating the hospital 9 or 10 and percentage of patients definitely recommending the hospital. Secondary outcomes were the average top-box score percentages for each of the 8 remaining dimensions of the FPS.

RESULTS

Between 2014 and 2019, there was a significant improvement in patients scoring the hospital 9 or 10 (56% to 61%) and patients definitely recommending (67% to 70%) the hospital. Significant increases in patient experiences over time were also observed in other dimensions, except for the dimension discharge. Hospital key informants reported various improvement strategies related to patient experiences with care and the FPS. Feedback to nursing wards (n = 44, 100%) and clinicians (n = 39, 89%) were most common. Overall, most improvement strategies were not or only weakly associated with patient experience ratings in 2019 and changes in ratings over time. Still, positive associations were discovered between the strategies 'nursing ward interventions' and 'hospital wide education' and recommendation of the hospital.

CONCLUSIONS

Patient experiences have improved modestly in Flemish acute-care hospitals. Hospitals report to have invested in patient experience improvement strategies but positive associations between such strategies and FPS scores are weak, although there is potential in further exploring nursing ward interventions and hospital wide education. Hospitals should continue their efforts to improve the patient's experience, but with a more targeted approach, taking the lessons learned on the efficacy of strategies into consideration.

Patient Satisfaction and Quality of Life Before and After Treatment of Pancreatic and Periampullary Cancer: A Prospective Multicenter Study

BACKGROUND

This study sought to assess patient satisfaction and quality of life (QoL) before and after treatment of pancreatic and periampullary cancer.

METHODS

We conducted a prospective multicenter study of patients treated for pancreatic and periampullary cancer. General patient satisfaction was measured using the EORTC satisfaction with care questionnaire (IN-PATSAT32) at baseline and 3 months after treatment initiation, with a 10-point change on the Likert scale considered clinically meaningful. QoL was measured using the EORTC Core Quality of Life Questionnaire (QLQ-C30). The influence of treatment (curative and palliative) on patient satisfaction and QoL was determined.

RESULTS

Of 100 patients, 71 completed follow-up questionnaires. General satisfaction with care decreased from 74.3 before treatment to 61.9 after treatment (P<.001), whereas global QoL increased from 68.4 to 71.4 (P=.39). Clinically meaningful reductions were also observed for the reported interpersonal skills of doctors (from 73.4 to 63.3) and exchange of information within the care team (from 63.5 to 52.5). Satisfaction scores were lower for patients treated with curative intent than for those treated with palliative intent regarding interpersonal skills of doctors (P=.01), information provision by doctors (P=.004), information provision by nurses (P=.02), availability of nurses (P=.004), exchange of information within the care team (P=.01), and hospital access (P=.02). In multivariable analysis, clinicopathologic or QoL factors were not independently associated with general patient satisfaction.

CONCLUSIONS

Satisfaction with care, but not QoL, decreased after pancreatic cancer treatment. Improvements in communication and interpersonal skills are needed to maintain patient satisfaction after treatment.

A Review of Best Practices for Monitoring and Improving Inpatient Pediatric Patient Experiences

CONTEXT

Achieving high-quality patient-centered care requires assessing patient and family experiences to identify opportunities for improvement. With the Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey, hospitals can assess performance and make national comparisons of inpatient pediatric experiences. However, using patient and family experience data to improve care remains a challenge.

OBJECTIVE

We reviewed the literature on best practices for monitoring performance and undertaking activities aimed at improving pediatric patient and family experiences of inpatient care.

DATA SOURCES

We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO.

STUDY SELECTION

We included (1) English-language peer-reviewed articles published from January 2000 to April 2019; (2) articles based in the United States, United Kingdom, or Canada; (3) articles focused on pediatric inpatient care; (4) articles describing pediatric patient and family experiences; and (5) articles including content on activities aimed at improving patient and family experiences. Our review included 25 articles.

DATA EXTRACTION

Two researchers reviewed the full article and abstracted specific information: country, study aims, setting, design, methods, results, Quality Improvement (QI) initiatives performed, internal reporting description, best practices, lessons learned, barriers, facilitators and study implications for clinical practice, patient-experience data collection, and QI activities. We noted themes across samples and care settings.

RESULTS

We identified 10 themes of best practice. The 4 most common were (1) use evidence-based approaches, (2) maintain an internal system that communicates information and performance on patient and family experiences to staff and hospital leadership, (3) use experience survey data to initiate and/or evaluate QI interventions, and (4) identify optimal times (eg, discharge) and modes (eg, print) for obtaining patient and family feedback. These correspond to adult inpatient best practices.

CONCLUSIONS

Both pediatric and adult inpatient best practices rely on common principles of culture change (such as evidence-based clinical practice), collaborative learning, multidisciplinary teamwork, and building and/or supporting a QI infrastructure that requires time, money, collaboration, data tracking, and monitoring. QI best practices in both pediatric and adult inpatient settings commonly rely on identifying drivers of overall ratings of care, rewarding staff for successful implementation, and creating easy-to-use and easy-to-access planning and QI tools for staff.

Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices

BACKGROUND

Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience.

OBJECTIVE

To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings.

DESIGN

Retrospective cohort.

PARTICIPANTS

A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017.

MAIN MEASURES

We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day.

RESULTS

We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break.

CONCLUSIONS

In primary care, appointment time of day is associated with patient-reported experience.

Evaluating Digital Maturity and Patient Acceptability of Real-Time Patient Experience Feedback Systems: Systematic Review

Background

One of the essential elements of a strategic approach to improving patients’ experience is to measure and report on patients’ experiences in real time. Real-time feedback (RTF) is increasingly being collected using digital technology; however, there are several factors that may influence the success of the digital system.

Objective

The aim of this review was to evaluate the digital maturity and patient acceptability of real-time patient experience feedback systems.

Methods

We systematically searched the following databases to identify papers that used digital systems to collect RTF: The Cochrane Library, Global Health, Health Management Information Consortium, Medical Literature Analysis and Retrieval System Online, EMBASE, PsycINFO, Web of Science, and CINAHL. In addition, Google Scholar and gray literature were utilized. Studies were assessed on their digital maturity using a Digital Maturity Framework on the basis of the following 4 domains: capacity/resource, usage, interoperability, and impact. A total score of 4 indicated the highest level of digital maturity.

Results

RTF was collected primarily using touchscreens, tablets, and Web-based platforms. Implementation of digital systems showed acceptable response rates and generally positive views from patients and staff. Patient demographics according to RTF responses varied. An overrepresentation existed in females with a white predominance and in patients aged ≥65 years. Of 13 eligible studies, none had digital systems that were deemed to be of the highest level of maturity. Three studies received a score of 3, 2, and 1, respectively. Four studies scored 0 points. While 7 studies demonstrated capacity/resource, 8 demonstrated impact. None of the studies demonstrated interoperability in their digital systems.

Conclusions

Patients and staff alike are willing to engage in RTF delivered using digital technology, thereby disrupting previous paper-based feedback. However, a lack of emphasis on digital maturity may lead to ineffective RTF, thwarting improvement efforts. Therefore, given the potential benefits of RTF, health care services should ensure that their digital systems deliver across the digital maturity continuum.

Socio-demographic determinants of women's satisfaction with prenatal and delivery care services in Italy

OBJECTIVE

The aim of this study was to examine the extent to which socio-demographic variables affect women's satisfaction regarding antenatal and perinatal care.

DESIGN

To take into account the role of the context in shaping women's satisfaction, we used multilevel models, with women at the lower level, and the health districts of residence, or the hospitals in which the delivery took place, at the higher level.

SETTING

Tuscany (Italy).

PARTICIPANTS

The study is based on a representative survey focused on the satisfaction and experience of 4598 new mothers who gave birth in one of the 25 hospitals in Tuscany (Italy) in 2012.

MAIN OUTCOME MEASURES

Women's overall satisfaction in the prenatal period and their overall satisfaction during hospitalization for delivery.

RESULTS

Regarding pregnancy, women's satisfaction increased with age, and was generally higher among foreign women coming from non-Western countries and among highly educated women. Regarding delivery, age proved insignificant, whereas citizenship and education maintained the same association with satisfaction. Contrary to our expectations, the number of previous pregnancies turned out to be insignificant.

CONCLUSIONS

Our findings suggest that the quality of maternity services was perceived differently in different socio-demographic groups: women's expectations affected satisfaction, but in different ways, in various socio-demographic groups, both during pregnancy and at delivery. Keeping these socio-demographic factors into account in the analysis of satisfaction may help organisations to identify areas where pregnancy and delivery services can be better targeted and where increasing awareness among professionals in their everyday practice is most needed.

Satisfaction with Mental Health Navigation Services: Piloting an Evaluation with a New Scale

As mental health navigation services continue to be implemented, the need for valid and reliable tools to assess the quality of these services increases. While case managers target individuals with severe mental illness and aim to reduce burden and cost, and increase independence, navigation services target all individuals with a range of mental health and/or substance use issues, with the aim of reducing barriers to treatment and coordinating individualized care. The current study evaluated satisfaction with a navigation service using a new 22-item questionnaire, the Navigation Satisfaction Tool (NAVSAT). Forty clients completed a web-based version of the NAVSAT to evaluate satisfaction with a family mental health navigation service in Toronto, Canada. Descriptive statistics on the sample and range of treatments/services are provided. The NAVSAT has excellent reliability (Cronbach's alpha = 0.96) and face validity. Satisfaction with the following navigation-level factors were the best predictors of overall satisfaction with navigation; the navigator's ability to recommend the appropriate treatment (β = 0.116, p = .05), intake procedures (β = 0.364, p = .005), and the principal contact's satisfaction with his/her frequency of contact with the navigator (β = 0.602, p = .001). Satisfaction with the following provider-level factors were the best predictors of overall satisfaction with the referred service; the referred service's ability to improve the youth's well being (β = 0.684, p < .001), and the referred service's ability to listen and understand the family's concerns (β = 0.356, p = .001). The NAVSAT appears to be a reliable tool for measuring satisfaction in the current sample. If these findings are replicated in a larger population serving youth and young adults in transition, the NAVSAT may prove to be a helpful guide for program evaluation and development for navigation and treatment services for this population.

Determinants of Parent Satisfaction with Emergency or Urgent Care When the Patient Has Autism

OBJECTIVE

The purpose of this study was to identify factors that predict parent satisfaction (PS) with their child with autism spectrum disorder (ASD)'s visit to a hospital emergency department (ED) or urgent care (UC) center.

METHODS

Parents recruited through a national database whose child (3-21 years; N = 378) with ASD had been treated in an ED/UC center within the previous 3 years completed an anonymous on-line questionnaire. They answered questions about whether they were satisfied overall with the visit and the care provided, their demographics, patient characteristics, their expectations and preparation for the visit, and the ED/UC center experience itself, including their observations of staff interpersonal and communication skills (ICSs) and behaviors, and whether the patient was disruptive (D). Multiple correspondence analysis (MCA) was used to demonstrate the relative effects of individual variables on PS.

RESULTS

Among the 10 most important determinants of PS with the visit were the 9 assessed staff ICS behaviors. These were followed by shorter than expected waiting time and the patient not being disruptive (ND) during the visit. PS was not associated with any of the 3 measures of patient disability severity (ASD subtype, communicative competence, or restrictiveness of educational placement), whether the patient is hyperreactive to sensory stimuli, reason for the visit, or parent's education.

CONCLUSION

PS with an ED/UC center visit when the patient has autism depends mostly on the quality of staff interactions with the patient and family. It is important for ED/UC center administrators to ensure that staff understand how to interact and communicate effectively with patients with ASD and their families.

Exploring the impact and use of patients' feedback about their care experiences in general practice settings-a realist synthesis

Background

Policy encourages health care providers to listen and respond to feedback from patients, expecting that it will enhance care experiences. Enhancement of patients' experiences may not yet be a reality, particularly in primary health care settings.

Objective

To identify the issues that influence the use and impact of feedback in this context.

Design and Setting

A realist synthesis of studies of the use of patient feedback within primary health care settings.

Methods

Structured review of published studies between 1971 and January 2015.

Results

Eighteen studies were reported in 20 papers. Eleven studies reported patient survey scores as a primary outcome. There is little evidence that formal patient feedback led to enhanced experiences. The likelihood of patient feedback to health care staff stimulating improvements in future patients' experiences appears to be influenced predominantly by staff perceptions of the purpose of such feedback; the validity and type of data that is collected; and where, when and how it is presented to primary health care teams or practitioners and teams' capacity to change.

Conclusions

There is limited research into how patient feedback has been used in primary health care practices or its usefulness as a stimulant to improve health care experience. Using a realist synthesis approach, we have identified a number of contextual and intervention-related factors that appear to influence the likelihood that practitioners will listen to, act on and achieve improvements in patient experience. Consideration of these may support research and improvement work in this area.

Factors associated with patient-satisfaction in student-led physiotherapy clinics: A qualitative study

BACKGROUND AND PURPOSE

Student-led physiotherapy clinics are a valuable means for providing clinical education opportunities for student learning and providing cost-effective services to the public. Understanding patient satisfaction within the student-led physiotherapy clinic setting is important to inform organizational, educational, and clinical processes that aim to balance both student learning experiences and quality patient care.

DESIGN

A cross-sectional qualitative design using semi-structured interviews.

RESULTS

A total of 20 patients from three different university student-led physiotherapy clinics were interviewed. Five major themes were associated with patient satisfaction, style of supervision, student-supervisor relationship, quality of physiotherapy care, student qualities and cost, and location of the service.

CONCLUSION

The results emphasize the importance placed by patients on effective communication, as well as the relationship between the supervisor and student overseeing their care. The findings highlight the influence of both the student and supervisor on patient satisfaction and provide insight into the style of student supervision from the perspective of the patient.

New Instrument to Measure Hospital Patient Experiences in Flanders

Implementing a standardized patient experience survey may initiate a process to apply pressure on hospitals to attend to improving patient experiences. In Flanders, Belgium, the Flemish Patient Survey was developed between 2011 and 2015. A preliminary version was developed from a scoping review and patient and expert focus groups, and included 27 items for eight hypothesized dimensions: 'preparing for hospital stay', 'information and communication', 'coordination', 'respect', 'privacy', 'safe care', pain management', and 'participation'. Exploratory factor analysis for 1076 patients in 17 hospitals found that the data did not fit the dimensions. Adaptations in item wording and response categories were based on the US Hospital Consumer Assessment of Healthcare Providers and Systems. The revised version showed excellent model fit in 22,143 patients in 37 hospitals. Multiple group analysis pointed to evidence of measurement invariance over time across mode of administration, type of nursing unit, and various patient characteristics. Fostering a collaborative approach thus proved successful in implementing a standardized patient experience survey. The most recent findings (2016) illustrate substandard performance and a need for patient-mix adjustment. The Flemish government developed a dedicated website to make findings publicly available and the federal government currently considers patient experiences in devising a pay-for-quality scheme.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Systematic review of approaches to using patient experience data for quality improvement in healthcare settings

OBJECTIVES

Explore how patient-reported experience measures (PREMs) are collected, communicated and used to inform quality improvement (QI) across healthcare settings.

DESIGN

Systematic review.

SETTING

Various primary and secondary care settings, including general practice, and acute and chronic care hospitals.

PARTICIPANTS

A full range of patient populations from (children through to the elderly) and staff (from healthcare practitioners to senior managers).

METHODS

Scientific databases were searched (CINAHL, PsycINFO, MEDLINE and Cochrane Libraries) as was grey literature. Qualitative and quantitative studies describing collection of PREM data and subsequent QI actions in any healthcare setting were included. Risk of bias was assessed using established criteria. Of 5312 initial hits, 32 full texts were screened, and 11 were included.

RESULTS

Patient experience data were most commonly collected through surveys and used to identify small areas of incremental change to services that do not require a change to clinician behaviour (eg, changes to admission processes and producing educational materials). While staff in most studies reported having made effective improvements, authors struggled to identify what those changes were or the impact they had.

CONCLUSIONS

Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient experience.

Trends in patient satisfaction in Dutch university medical centers: room for improvement for all

BACKGROUND

Results of patient satisfaction research provide hospitals areas for quality improvement. Although it may take several years to achieve such improvement, not all hospitals analyze changes in patient satisfaction over time structurally. Consequently, they lack information from patients' perspective on effectiveness of improvement programs. This study presents a trend analysis of the patient satisfaction scores in the eight university medical centers in the Netherlands. We focus on the trends, effect size and its consequences for improving patient-centered care.

METHODS

The Core Questionnaire for the assessment of Patient satisfaction (COPS) was used in four large-scale nationwide comparative studies (2003-2009). Data were analyzed at a national level, and for each academic hospital separately. We analyzed the polynomial contrasts in the four measurements by performing an univariate analysis of variance (ANCOVA). The trend lines are presented graphically, with the means, SD, F-statistics and the standardized effect size including confidence intervals expressed by Cohen's d. By analyzing the (logit transformed) percentages of very satisfied patients we examined the change scores.

RESULTS

The dataset consisted of 58,055 inpatients and 79,498 outpatients. Significant positive trends were found on national level and hospital level, especially in outpatient departments. Improvement was especially seen on the dimensions "information" and "discharge and aftercare". Not only university medical centers with a lower score at the start, but surprisingly some best practices and university medical centers with a high initial score improved.

CONCLUSIONS

We conclude that significant trends in patient satisfaction can be identified on a national and a hospital level, in inpatient and outpatient departments. The observed effect size expressed by Cohen's d is rather small. Hospitals have found room for improvement, even hospitals with initial high satisfaction scores. We recommend that hospitals monitor their patient satisfaction scores over time and relate these to quality interventions and organizational changes. Furthermore, we recommend to expand the research to subgroups of unsatisfied patients to improve patient-centered care for all patients.

Does feedback influence patient - professional communication? Empirical evidence from Italy

Healthcare providers often look for feedback from patient surveys. Does health-professional awareness of patient survey results improve communication between patients and providers? To test this hypothesis, we analyzed the data of two surveys on organizational-climate and patient experience in Italy. The two surveys were conducted in 26 hospitals in the Tuscany region and involved 8942 employees and 5341 patients, respectively. Statistical analysis showed that the patient experience index significantly improved by 0.35 points (scale: 0-100) when the professionals' knowledge of the patient survey results increased by 1%. These findings suggest that the control systems should focus more on the dissemination phase of patient survey results among health professionals in order to improve the quality of services.

[Perceived satisfaction and usefulness of suicide prevention information for patients and relatives]

OBJECTIVE

To assess the satisfaction of persons with suicidal behaviour and their relatives using patient information material included in the Clinical Practice Guidelines on Prevention and Treatment of Suicidal Behaviour.

METHOD

The sample was made up of 57 patients with suicidal ideation or behaviour, and 52 relatives. The participants were recruited through a suicide prevention programme (Programa de intervención intensiva en conducta suicida [PII] - Suicidal Behaviour Intensive Intervention Programme) and a family association (Federación de Asociaciones de Familiares y Personas con enfermedad mental de Galicia [FEAFES] - Galician Federation of Associations of Relatives and Persons with mental diseases). An ad-hoc questionnaire was designed to ascertain the degree of perceived satisfaction and usefulness of using the information included in the guidelines.

RESULTS

The descriptive data of the sample is presented, along with an exploratory factorial analysis of the questionnaire that yielded two dimensions, i.e., format and usefulness. Patients scored significantly lower than the relatives in two dimensions; nevertheless, no significant differences were found between the two groups in the level of general satisfaction. The socio-demographic variables did not influence the results. Similarly, no differences were observed between patients with and without history of suicidal behaviour. Participants stressed that Primary Care was the setting best suited for dissemination of this type of information.

CONCLUSIONS

In general, both patients and relatives displayed a high level of satisfaction with the patient information material assessed. Furnishing information of this type to patients with suicidal ideation and/or behaviour could act as a preventive-educational tool.

Dissemination of performance information and continuous improvement: A narrative systematic review

PURPOSE

Developing a performance measure and reporting the results to support decision making at an individual level has yielded poor results in many health systems. The purpose of this paper is to highlight the factors associated with the dissemination of performance information that generate and support continuous improvement in health organizations.

DESIGN/METHODOLOGY/APPROACH

A systematic data collection strategy that includes empirical and theoretical research published from 1980 to 2010, both qualitative and quantitative, was performed on Web of Science, Current Contents, EMBASE and MEDLINE. A narrative synthesis method was used to iteratively detail explicative processes that underlie the intervention. A classification and synthesis framework was developed, drawing on knowledge transfer and exchange (KTE) literature. The sample consisted of 114 articles, including seven systematic or exhaustive reviews.

FINDINGS

Results showed that dissemination in itself is not enough to produce improvement initiatives. Successful dissemination depends on various factors, which influence the way collective actors react to performance information such as the clarity of objectives, the relationships between stakeholders, the system's governance and the available incentives.

RESEARCH LIMITATIONS/IMPLICATIONS

This review was limited to the process of knowledge dissemination in health systems and its utilization by users at the health organization level. Issues related to improvement initiatives deserve more attention.

PRACTICAL IMPLICATIONS

Knowledge dissemination goes beyond better communication and should be considered as carefully as the measurement of performance. Choices pertaining to intervention should be continuously prompted by the concern to support organizational action.

ORIGINALITY/VALUE

While considerable attention was paid to the public reporting of performance information, this review sheds some light on a more promising avenue for changes and improvements, notably in public health systems.

The road to patient experience of care measurement: lessons from the United States

Patient-centered care has become an increasing priority in the United States and plays a prominent role in recent healthcare reforms. One way the country has managed to advance patient-centered care is through establishment of a family of national patient experience surveys (the Consumer Assessment of Healthcare Providers and Systems Plans (CAHPS). CAHPS is publicly reported for several types of providers and was recently tied to hospital reimbursement. This is part of a trend over the last two decades that has shifted provider-patient relationships from a traditional paternal approach to customer service and then to clinical partnership. The health care system in Israel, however, is still struggling to overcome barriers to change in this area. While community based biannual patient experience surveys are conducted by the Myers-JDC-Brookdale Institute, there is no comprehensive national approach to measuring the patient experience across a broad range of settings. Only recently did the Israeli Ministry of Health take its first steps to include patient experience as a dimension of health care quality.

In its current position, Israel should learn from the U.S. experience with policies promoting patient-centered care, and specifically the impact on clinical services of measuring the patient experience. Looking at what has happened in the United States, we suggest three main lessons. First, there is a need for a set of national patient experience surveys that would be publicly reported and eventually tied to provider reimbursement. Secondly, the national survey tools should be customized to the unique characteristics of Israeli society and draw from recent research on patient-centeredness to include new and important domains such as patient activation and shared decision-making. Finally, newer technological approaches should be explored with the aim of increasing response rates and the timeliness and usefulness of the surveys.

The multiple causal pathways between performance measures' use and effects

In recent decades, there has been a growing interest in the design and implementation of systems using public reporting of performance measures to improve performance. In their simplest form, such interventions rest on the market-based logic of consumers using publicly released information to modify their behavior, thereby penalizing poor performers. However, evidence from large-scale efforts to use public reporting of performance measures as an instrumental performance improvement tool suggests that the causal mechanisms involved are much more complex. This article offers a typology of four different plausible causal pathways linking public reporting of performance measures and performance improvement. This typology rests on a variety of conceptual models and a review of available empirical evidence. We then use this typology to discuss the core elements that need to be taken into account in efforts to use public reporting of performance measures as a performance improvement tool.

Using a standardized assessment tool to measure patient experience on a seizure monitoring unit compared to a general neurology unit

Seizure monitoring unit (SMU) research typically focuses on diagnostic utility and medical management of epilepsy. However, patient safety and satisfaction are also imperative to high-quality SMU care. This study uses a standardized tool to evaluate patient experience on a SMU compared to a general neurology unit (GNU). The 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was telephone-administered post-discharge to a sample of patients from our SMU and GNU. Data from a 33-month period were reviewed, encompassing 217 SMU patient admissions and 317 GNU patient admissions. On average, SMU patients were 14.7 years younger and stayed in the hospital 4.2 days longer than GNU patients. SMU patients provided lower overall mental health ratings (p<.001), perceived nursing staff to be more responsive to the call button (p<.001), and assigned higher overall ratings to their stay (p<0.05). Lower education was associated with more favorable hospital ratings on both units (p<0.05).

Use of qualitative methods in published health services and management research: a 10-year review

Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.

Patients' perspectives of patient-centredness as important in musculoskeletal physiotherapy interactions: a qualitative study

OBJECTIVE

To determine patients' perspectives of components of patient-centred physiotherapy and its essential elements.

DESIGN

Qualitative study using semi-structured interviews to explore patients' judgements of patient-centred physiotherapy. Grounded theory was used to determine common themes among the interviews and develop theory iteratively from the data.

SETTING

Musculoskeletal outpatient physiotherapy at a provincial city hospital.

PARTICIPANTS

Eight individuals who had recently received physiotherapy.

RESULTS

Five categories of characteristics relating to patient-centred physiotherapy were generated from the data: the ability to communicate; confidence; knowledge and professionalism; an understanding of people and an ability to relate; and transparency of progress and outcome. These categories did not tend to occur in isolation, but formed a composite picture of patient-centred physiotherapy from the patient's perspective.

CONCLUSIONS AND PRACTICE IMPLICATIONS

This research elucidates and reinforces the importance of patient-centredness in physiotherapy, and suggests that patients may be the best judges of the affective, non-technical aspects of a given healthcare episode.

Usefulness of a national parent experience survey in quality improvement: views of paediatric department employees

Objectives

This study presents results from an electronic survey among paediatric department employees, addressing employees' attitudes and use of results from a national parent experience survey carried out in 2005.

Methods

Electronic questionnaire survey of employees from each of the 20 paediatric departments included in the national survey, with a response rate of 87%.

Results

The employees had favourable opinions of user experience surveys, and the results from the national survey were well known among both managers and other personnel. User experience surveys were considered important, and 56% reported that they had implemented improvement actions addressing problems identified in the national survey. Managers reported more often than staff without managerial responsibility that the results had been informally discussed, and that the survey was useful for their own department. Department leaders were more positive to the usefulness of the survey than non-leaders. Significant differences in attitudes were found between physicians and other health personnel.

Conclusion

Employees in the paediatric departments were positive to user experience surveys, and the surveys have a potential to be actively used in quality improvement actions. Effects of the quality improvement initiatives should be assessed in future parent experience surveys.

Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction

BACKGROUND

Hospitals use patient satisfaction surveys to assess their quality of care. A key question is whether these data provide valid information about the medically related quality of hospital care. The objective of this study was to determine whether patient satisfaction is associated with adherence to practice guidelines and outcomes for acute myocardial infarction and to identify the key drivers of patient satisfaction.

METHODS AND RESULTS

We examined clinical data on 6467 patients with acute myocardial infarction treated at 25 US hospitals participating in the CRUSADE initiative from 2001 to 2006. Press Ganey patient satisfaction surveys for cardiac admissions were also available from 3562 patients treated at these same 25 centers over this period. Patient satisfaction was positively correlated with 13 of 14 acute myocardial infarction performance measures. After controlling for a hospital's overall guideline adherence score, higher patient satisfaction scores were associated with lower risk-adjusted inpatient mortality (P=0.025). One-quartile changes in both patient satisfaction and guideline adherence scores produced similar changes in predicted survival. For example, a 1-quartile change (75th to 100th) in either the patient satisfaction score or the guideline adherence score yielded the same change in predicted survival (odds ratio, 1.24; 95% CI, 1.02 to 1.49; and odds ratio, 1.24; 95% CI, 1.08 to 1.41, respectively). Satisfaction with nursing care was the most important determinant of overall patient satisfaction (P<0.001).

CONCLUSIONS

Higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients are good discriminators of the type of care they receive. Thus, patients' satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care.

The path of patient loyalty and the role of doctor reputation

Patient loyalty to doctors is relevant to medical services in which doctor-patient relationships are central and for which competition has increased in recent years. This study aims at understanding the process whereby patients develop loyalty to their doctor and doctor reputation has a moderating role. Based on a randomization of subjects, the study offers and tests an explanation chain representing key variables determining patient loyalty: patient commitment, trust and satisfaction, and doctor reputation. Primary data was collected using a structured questionnaire from a quota sample of regular patients in a large city in South America. The patients most committed to their doctor are more loyal to them. In turn, commitment is determined by patient trust, which is determined by patient satisfaction. Doctor reputation positively influences both patient trust and satisfaction. The explanation chain not only gives an account of how patient loyalty is formed; it also identifies a path health professionals can follow to secure patient loyalty.

Online assessment of patients' views on hospital performances using Rasch model's KIDMAP diagram

Background

To overcome the drawback of individual item-by-item box plots of disclosure for patient views on healthcare service quality, we propose to inspect interrelationships among items that measure a common entity. A visual diagram on the Internet is developed to provide thorough information for hospitals.

Methods

We used the Rasch rating scale model to analyze the 2003 English inpatient questionnaire data regarding patient satisfactory perception, which were collected from 169 hospitals, examined model-data fit, and developed a KIDMAP diagram on the Internet depicting the satisfaction level of each hospital and investigating aberrant responses with Z-scores and MNSQ statistics for individual hospitals. Differential item functioning (DIF) analysis was conducted to verify construct equivalence across types of hospitals.

Results

18 of the 45 items fit to the model's expectations, indicating they jointly defined a common construct and an equal-interval logit scale was achieved. The most difficult aspect for hospitals to earn inpatients' satisfaction were item 29 (staff told you about any medication side effects to watch when going home). No DIF in the 18-item questionnaire was found between types of hospitals, indicating the questionnaire measured the same construct across hospitals. Different types of hospitals obtained different levels of satisfaction. The KIDMAP on the Internet provided more interpretable and visualized message than traditional item-by-item box plots of disclosure.

Conclusion

After removing misfit items, we find that the 18-item questionnaire measures the same construct across types of hospitals. The KIDMAP on the Internet provides an exemplary comparison in quality of healthcare. Rasch analysis allows intra- and inter-hospital performances to be compared easily and reliably with each other on the Internet.

Characteristics and outcomes of America's lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the United States

BACKGROUND

Studies suggest that most hospitals now have relatively high adherence with recommended acute myocardial infarction (AMI) process measures. Little is known about hospitals with consistently poor adherence with AMI process measures and whether these hospitals also have increased patient mortality.

METHODS AND RESULTS

We conducted a retrospective study of 2761 US hospitals reporting AMI process measures to the Center for Medicare and Medicaid Services Hospital Compare database during 2004 to 2006 that could be linked to 2005 Medicare Part A data. The main outcome measures were hospitals' combined compliance with 5 AMI measures (aspirin and beta-blocker on admission and discharge and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge for patients with left ventricular dysfunction) and risk-adjusted 30-day mortality for 2005. We stratified hospitals into those with low AMI adherence (ranked in the lowest decile for AMI adherence for 3 consecutive years [2004-2006, n=105]), high adherence (ranked in the top decile for 3 consecutive years [n=63]), and intermediate adherence (all others [n=2593]). Mean AMI performance varied significantly across low-, intermediate-, and high-performing hospitals (mean score, 68% versus 92% versus 99%, P<0.001). Low-performing hospitals were more likely than intermediate- and high-performing hospitals to be safety-net providers (19.2% versus 11.0% versus 6.4%; P=0.005). Low-performing hospitals had higher unadjusted 30-day mortality rates (23.6% versus 17.8% versus 14.9%; P<0.001). These differences persisted after adjustment for patient characteristics (16.3% versus 16.0% versus 15.7%; P=0.02).

CONCLUSIONS

Consistently low-performing hospitals differ substantially from other US hospitals. Targeting quality improvement efforts toward these hospitals may offer an attractive opportunity for improving AMI outcomes.

Physicians' Views on Public Reporting of Hospital Quality Data

This article describes physicians' responses to patient questions and physicians' views about public reports on hospital quality. Interviews with 56 office-based physicians in seven states/regions used hypothetical scenarios of patients questioning referrals based on public reports of hospital quality. Responses were analyzed using an iterative coding process to develop categories and themes from data. Four themes describe physicians' responses to patients: (a) rely on existing physician—patient relationships, (b) acknowledge and consider patient perspectives, (c) take actions to follow up on patient concerns, and (d) provide patients' perspectives on quality reports. Three themes summarize responses to hospital quality reports: perceived lack of methodological rigor, content considerations in reports, and attitudes/experience regarding reports. Findings suggest that physicians take seriously patients' questions about hospital-quality reports and consider changing referral recommendations based on their concerns and/or preferences. Results underscore the importance of efforts by report developers and physician outreach/education to address physicians' methodological concerns.

Performance reporting to help organizations promote quality improvement

In healthcare, a great deal of time, money and energy go into producing public reports for a wide range of audiences. Reporting strategies often target audiences like the general public, whose behaviour is not readily changed by the information in report cards. However, when it comes to effectively targeting groups that can actually use the data to achieve significant impacts, one audience stands out from the rest: health system managers and providers, who can interpret and apply performance data to improve the quality of care their organizations deliver. The evidence behind performance reports was recently summarized in Evidence Boost for Quality, a special subseries of Evidence Boost, produced by the Canadian Health Services Research Foundation to showcase healthcare issues where research indicates a preferred course of action in health services management and policy. To access archived issues of Evidence Boost, visit <http://www.chsrf.ca/mythbusters/eb_e.php>.

Selecting high priority quality measures for breast cancer quality improvement

BACKGROUND

Although many quality measures have been created, there is no consensus regarding which are the most important. We sought to develop a simple, explicit strategy for prioritizing breast cancer quality measures based on their potential to highlight areas where quality improvement efforts could most impact a population.

METHODS

Using performance data for 9019 breast cancer patients treated at 10 National Comprehensive Cancer Network institutions, we assessed concordance relative to 30 reliable, valid breast cancer process-based treatment measures. We identified 4 attributes that indicated there was room for improvement and characterized the extent of burden imposed by failing to follow each measure: number of nonconcordant patients, concordance across all institutions, highest concordance at any 1 institution, and magnitude of benefit associated with concordant care. For each measure, we used data from the concordance analyses to derive the first 3 attributes and surveyed expert breast cancer physicians to estimate the fourth. A simple algorithm incorporated these attributes and produced a final score for each measure; these scores were used to rank the measures.

RESULTS

We successfully prioritized quality measures using explicit, objective methods and actual performance data. The number of nonconcordant patients had the greatest influence on the rankings. The highest-ranking measures recommended chemotherapy and hormone therapy for hormone-receptor positive tumors and radiation therapy after breast-conserving surgery.

CONCLUSIONS

This simple, explicit approach is a significant departure from methods used previously, and effectively identifies breast cancer quality measures that have broad clinical relevance. Systematically prioritizing quality measures could increase the efficiency and efficacy of quality improvement efforts and substantially improve outcomes.

Experiences with hospital care: perspectives of black and Hispanic patients

BACKGROUND

Significant racial and ethnic differences along several dimensions of patients'experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described.

METHODS

We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients' experiences with care were most important in determining overall levels of satisfaction.

RESULTS

Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff.

CONCLUSIONS

Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.

Publication of quality report cards and trends in reported quality measures in nursing homes

OBJECTIVE

To examine associations between nursing homes' quality and publication of the Nursing Home Compare quality report card.

DATA SOURCES/STUDY SETTINGS

Primary and secondary data for 2001-2003: 701 survey responses of a random sample of nursing homes; the Minimum Data Set (MDS) with information about all residents in these facilities, and the Nursing Home Compare published quality measure (QM) scores.

STUDY DESIGN

Survey responses provided information on 20 specific actions taken by nursing homes in response to publication of the report card. MDS data were used to calculate five QMs for each quarter, covering a period before and following publication of the report. Statistical regression techniques were used to determine if trends in these QMs have changed following publication of the report card in relation to actions undertaken by nursing homes.

PRINCIPAL FINDINGS

Two of the five QMs show improvement following publication. Several specific actions were associated with these improvements.

CONCLUSIONS

Publication of the Nursing Home Compare report card was associated with improvement in some but not all reported dimensions of quality. This suggests that report cards may motivate providers to improve quality, but it also raises questions as to why it was not effective across the board.

Patient satisfaction with treatment after acute myocardial infarction: role of psychosocial factors

OBJECTIVE

To determine if psychosocial status influences treatment satisfaction, a quality-of-care indicator, of patients who were hospitalized for acute myocardial infarction (AMI).

METHODS

Psychosocial variables (social support, dispositional optimism, and depression) were assessed in 1847 AMI patients who completed a 1-month assessment in Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), a multicenter, prospective cohort study. Patients' treatment satisfaction was determined using the Treatment Satisfaction scale of the Seattle Angina Questionnaire. The association between psychosocial variables and treatment satisfaction-adjusted for site, sociodemographics, medical history, clinical presentation, and treatment procedures-was evaluated using a censored normal model.

RESULTS

Study participants were primarily white (77.6%) and male (68.8%), with a mean age of 60.6 +/- 12.7 (SD) years. Satisfaction with posthospitalization treatment following AMI increased as social support (Wald chi(2) = 35.02, p < .001) and dispositional optimism (beta = 1.42; 95% CI 0.24, 2.60) increased. Participants with mild (-3.10, 95% CI -5.77, -0.44), moderate (-4.77, 95% CI -8.16, -1.38), moderately severe (-8.49, 95% CI -13.47, -3.52), and severe (-11.65, 95% CI -18.77, -4.53) depression had significantly worse treatment satisfaction compared with the nondepressed participants.

CONCLUSION

Assessing psychosocial variables, such as social support, dispositional optimism, and depression severity before hospital discharge, may indicate who is likely to be more satisfied with posthospitalization cardiac care 1 month following AMI. Without controlling for psychosocial status, treatment satisfaction may be a biased indicator of quality. Future studies should evaluate whether psychosocial intervention after AMI can improve satisfaction.

Understanding the reporting practices of CAHPS sponsors

This article examines the reporting of Consumer Assessment of Healthcare Providers and Systems (CAHPSO) consumer experience data by sponsors, those that fund data collection and decide how information is summarized and disseminated. We found that sponsors typically publicly reported comparative data to consumers, employers, and/or purchasers. They presented health plan-level data in print and online at least annually, usually in combination with non-CAHPS information. Many provided trend data, comparisons to individual plans, and summary scores. Most shared information consistent with known successful reporting practices. Areas meriting attention include: tailoring reports to specific audiences, assessing literacy, planning dissemination, educating vendors, and evaluating products and programs.