International Journal for Quality in Health Care 15:163-168 (2003)
© 2003 International Society for Quality in Health Care
Paper |
Development of the Irish National Patient Perception of Quality of Care Survey
1Irish Health Services Accreditation Board
2Department of Health Science and Management, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
Objectives. This study aimed to develop a methodology suitable for assessing patients’ perception of quality of care received in Irish hospitals nationwide.
Setting. Thirteen acute care hospitals throughout Ireland participated in the study. Patients were surveyed approximately 3–6 weeks following discharge. The development work was undertaken by the Irish Society for Quality in Healthcare.
Design. The survey utilized Computer Aided Telephone Interviews to receive and collate patient feedback. The questionnaire was developed through utilization of focus groups and extensive piloting. Patients perceptions in a wide range of areas were examined including admission procedures, pain management, adherence to the patient charter, medication, and overall satisfaction.
Study participants. A total of 3757 patients were randomly selected for interview during the study period, of whom 3276 were eligible. The remaining 481 patients were unable to participate because of death, hospital re-admission, illness or severe cognitive impairments. With a total of 1950 respondents, this entire study yielded a response rate of 59.5%.
Results. This paper indicates how a national society may assist the health system in developing a survey for assessment of patients’ perception of quality of care. The results of the survey assisted organizations in identifying many improvement opportunities, mainly in relation to information and communication.
Keywords: Ireland, patient perception, quality, survey
It is safe to say that there is no precise definition of patient satisfaction. Pascoe defined patient satisfaction as ‘a health care recipient’s reaction to salient aspects of the context, process and result of their process experience’ [1], whereas Gerteis felt it could only be defined by examining two distinct dimensions: that of the ‘technical’ and the ‘experiential’ [2]. The ‘technical’ dimensions relate to the skills and techniques of those who provide the care and the effectiveness of the results. The ‘experiential’ aspect relates to the subjective perspective of quality based on a patient’s experiences with care.
There is a need to have a precise mechanism for the recording of patient perceptions, and this requirement has grown dramatically in recent years [3]. In 1994 the Department of Health and Children’s strategy document emphasized the need for a quality health service that ‘puts the patient first’ [4]. Patient perception is now accepted as one of the fundamental outcomes of care that is equal if not greater in stature to the more ‘technical’ aspects.
Measurement of patient perception serves many purposes for a health care organization [5]. There is a need to identify a structured mechanism for patient feedback and communication. Patient preferences can then be used to assist in deciding the way that care is provided. Patient satisfaction is also an important performance indicator of subsequent health-related behaviour and overall organizational effectiveness [6].
Background
Patient surveys are often criticized for their lack of structure and objectiveness [7]. Many Irish hospitals and health care institutions have utilized some type of patient satisfaction measure, such as comment cards and surveys. Very little progress has been made in developing a national survey instrument suitable for addressing issues surrounding satisfaction with Irish health care.
The development of the Irish National Patient Perception of the Quality of Healthcare Survey by the Irish Society for Quality in Healthcare was the first system-wide assessment of patients’ views of quality in health care in Ireland. The national survey initiative was launched in 1999 and conducted by 13 hospitals throughout Ireland as part of a collaborative effort to stimulate quality improvement, while enhancing the quality of care.
Methods
Planning for the Irish National Patient Perception of the Quality of Healthcare Survey initiative began in 1996 when the Royal College of Surgeons in Ireland (RCSI), in cooperation with Beaumont Hospital, Dublin, laid the foundation for this research. A steering committee, composed of six members representing a cross section of health care discipline, was responsible for the initial planning for the development of the survey instrument.
Questionnaire development
After an extensive review of the literature from both industry and health care and a review of survey instruments available, the characteristics that represent quality from the point of view of the Irish patient were determined through the use of focus groups [8]. Patients with recent experience of being hospitalized were selected for focus group participation. The discussion, led by a facilitator, was directed at eliciting the patients’ reactions to various components of care. Focus group findings together with the available literature led to the development of the original questionnaire.
The following year a joint approach was developed between Beaumont Hospital and St Vincent’s University Hospital, Dublin. This allowed preliminary versions to be piloted by being administered to discharged patients over a 2-year period.
Questionnaire specifications
This instrument comprised 95 items assessing eight dimensions of satisfaction with health care: overall impression, admission procedure, information given, care and assistance, tests and operations, pain management, physical environment, and the discharge procedure. Rather than solely focusing on whether patients were satisfied with their care, the approach taken was to ask patients to report on, as well as to rate, their care.
Sampling
The sampling method applied was a simple random sample without replacement within each hospital. Each member of the study sample, excluding those deemed either physically or mentally incapable of completing the survey and those who chose not to participate (informed consent), had an equal chance of being selected to complete the questionnaire. Medical and surgical specialties and subspecialties were included, while paediatric, psychiatric, and detoxification patients, along with those with severe cognitive impairment, were specifically excluded. The sampling period ran from January 2000 until October 2000, and spanned a 2-month period in each participating hospital. The sample size of 150 patients to be interviewed from each hospital was agreed upon at the pilot stage.
Delivery
The methodology applied was a survey conducted by means of a computer-aided telephone interview system (CATI). The surveys were administered by trained staff members of the Irish Society for Quality in Healthcare and RCSI medical students. Over a selected 2-month sampling period, 150 randomly selected in-patients from each participating hospital were interviewed on various aspects of their care.
The interviews were carried out approximately 3–6 weeks following the patients’ discharge, and the lists upon which the random sample was drawn excluded those who explicitly did not wish to participate in the study, those who were discharged to a place other than home (deceased, other hospital, nursing home, etc.) and, finally, those who were deemed inappropriate for inclusion (paediatric, psychiatric, and detoxification patients, alongside those with severe cognitive impairment).
The early involvement of staff was considered crucial to the success of the initiative [8]. To this end, all staff members were informed in writing about the survey prior to the sampling process. Furthermore, a series of information meetings were held with hospital staff. The purpose of these meetings was to outline the background and the rationale of the survey and to specify the types of patients who would be approached for interview, as well as to outline how the results would be disseminated to the staff following the survey.
Patient consent was obtained in one of two ways: (1) before hospital discharge, in which case a member of staff explained the purpose of the survey to each suitable in-patient and requested his or her permission to release his or her name and telephone number to the study group; or (2) after discharge, in which case a letter was posted to the patient’s home explaining the hospital’s participation in the survey and requesting permission to release the person’s name and telephone number to the study team.
Patients drawn as a result of the random sample were contacted by telephone for interview. All interviews were completed within 9 months. Patients were interviewed from Monday to Friday between 5pm and 9pm by trained interviewers. The surveys were administered using a CATI system. Patient consent was again sought at the start of the telephone interview, and up to three attempts were made to contact patients drawn for interview.
Patients were encouraged to answer all questions, even those of a sensitive nature, as honestly as possible, with the assurance that all responses would remain completely anonymous. In each instance confidentiality was assured.
Results
A total of 3757 patients were randomly selected for interview during the study period, of whom 3276 were eligible. The remaining 481 patients were unable to participate because of death, hospital re-admission, illness or severe cognitive impairment. With a total of 1950 respondents, this entire study yielded a response rate of 59.5%.
Only 3.3% of respondents felt that something carried out in relation to their care should not have been done, and almost one in 10 (9.8%) reported that there was something that should have been done for them while in hospital that was not. This ‘something’ often related either directly or indirectly to communication [5]. On arrival, some patients would have welcomed printed or oral information about the hospital and their daily routine. Others would have liked to be more informed about their condition and treatment during their stay in a way they understood, and given greater opportunities to discuss these matters with hospital staff.
These findings are consistent with comments made by respondents, many of whom believed that more printed information should have been offered to them at the time of their admission.
‘Any information I received about the hospital was from other patients in my ward and not from staff.’
‘I would have liked to know more about the hospital routine so I could anticipate when to be around.’
‘It was never explained to me when and how things occurred in the hospital during my stay. I had to learn this myself.’
‘It would have been a good idea to get some printed leaflets on the hospital and the routine.’
Furthermore, an appreciable number of respondents did not feel they had been offered enough information as to why they were admitted to hospital and their probable length of stay.
In relation to pain management, 66.4% of respondents recorded taking medication for pain relief during their stay. Almost one in five of those in receipt of pain medication had to ask for it, and 49.4% of these reported that they had to wait some time before any pain medication was administered. In terms of any other medication taken, 53.1% of respondents reported to have taken medication that they did not take prior to their hospital visit.
Response times in which pain relief was administered were generally fast, and the majority of respondents (95.9%) felt that they received the right amount of pain relief medication during their hospital stay. However, 49.6% of those who experienced a delay before pain medication was administered and believed their pain could have been relieved more effectively by quicker attention from hospital staff. Comments from these patients dominated discussions in relation to pain relief medication.
For others, the purpose of medication should have been explained in greater detail and administered more promptly. Similarly, many patients required clarification of tests and operations planned for them. Finally, some respondents would have welcomed more detailed information at discharge on how to continue with their lives upon returning home.
Encompassed in the 1994 Irish Department of Health and Children’s health strategy was the ‘Patients’ Charter’, which outlined patients’ rights in respect to the provision of acute hospital care [4]. Throughout the National Patient Perception of Quality of Healthcare Survey there were many issues raised in relation to the Charter. Table 3 presents breaches concerning the Patients’ Charter. With regards to teaching and research the Charter states:
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‘Permission must be sought before a consultant can involve you in the teaching of students....’
Results presented in Table 3, however, provide evidence to the contrary, where 42.2% of patients visited by medical students were not asked for permission prior to the visit. It is worth noting, however, that only 6.3% of those visited by medical students did not like it.
‘I did not mind that students were present during the procedure; I understand the value of this for their studies. Having said that, I would have appreciated if my permission was sought before the students entered the room.’
According to the Patients Charter, every hospital should have a detailed complaint procedure in place and this should be prominently displayed throughout the hospital. It was reported that 73.3% were unaware of a complaint procedure in the hospital they attended. While the majority of patients reported that they were involved in their treatment as much as they had wanted, 11.9% would have liked to be more involved in their own treatment and in decisions made about their care.
Areas of discontent aside, when respondents were asked whether they would prefer to return to the same hospital or not if they had to re-enter hospital, the majority of respondents (92.6%) reported that they would. This high percentage may in part be attributed to a fear of alternatives, especially when they are unknown. Similar high satisfaction rates have been reported in the UK [8] and France [9].
Discussion
The results of this survey have strengthened the view that when asking questions about satisfaction or asking patients to rate a hospital service, highly positive results can sometimes be produced that can often mask problems that may exist within the hospital [10]. In contrast, however, many patients reported problems when asked about specific aspects of their hospital care.
Many of the problems found in this survey related primarily to information and communication. On arrival, patients often received no printed information about the hospital. When admitted, patients may be told little about daily hospital routine, e.g. meal times, visiting hours, and time of ward rounds. During their stay patients felt poorly informed about their condition or treatment (tests, operations, medication) yet were given little opportunity to discuss these matters with staff. Finally, at discharge patients were rarely given information about how they should manage their transition from the acute hospital setting to their home.
The importance of good communication in the delivery of effective and appropriate medical care cannot be overstated. Unless mechanisms for communication among providers are firmly put in place, important admission and discharge activities may be duplicated or not addressed. Overall, this survey has identified specific nationwide quality improvements, in particular information and communication about discharge planning, treatment, and hospital routines [11].
Further development
This survey had several strengths. Its national scope enabled hospital peer group comparisons. The focus on various areas of hospital care recognizes that patient satisfaction is best conceptualized and measured as a multi-dimensional construct, and that patients may be more satisfied with some aspects of care than with others. The inclusion of patient reports as well as ratings helps in providing hospital staff with information on specific problems related to care that may need improvement.
One of the limitations of this survey, however, was that it had no objective measures of the impact of the events recorded on patient care. Responses to interview questions represented patients’ perceptions. It is necessary to be aware of how the service is perceived, and not merely if it is quantifiably delivered. For example, regardless of what information a patient has received, if they are not able to remember the information then the communication process has failed [11]. We must therefore realise that such negative responses do not necessarily mean a failure to provide, but sometimes represent a failure in the process.
This paper indicates how the Irish Society for Quality in Healthcare assisted the Irish health care system in developing a survey for the assessment of patients’ perception of quality of care. It also highlights the importance of good communication, which was the principal concern of patients surveyed.
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Address reprint requests to Professor Austin Leahy, Department of Health Science and Management, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland. E-mail: alfc{at}indigo.ie 
Accepted for publication December 18, 2002.
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- Department of Health. Shaping a Healthier Future: a Strategy for Effective Healthcare in the 1990s. Dublin: Government Publications, 1994.
- Fitzpatrick R. Surveys of patient satisfaction: important general considerations. Br Med J 1991; 302: 887–889.
- Lebov W, Ersoz CJ. The Healthcare Managers Guide to Continuous Quality Improvement. American Hospital Publishing Inc., Chicago, IL, 1991, pp. 105.
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- Bruster S, Jarman B, Bosanquet N, Weston D, Erens R, Delbanco TL. The patients view: a national survey of hospital patients. Br Med J 1994; 309: 1542–1546.
[Abstract/Free Full Text] - Labarere J, Francois P, Auquier P, Robert C, Fourny M. Development of a French inpatient satisfaction questionnaire. Int J Qual Health Care 2001; 13: 99–108.
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