International Journal for Quality in Health Care Advance Access originally published online on July 31, 2007
International Journal for Quality in Health Care 2007 19(5):281-288; doi:10.1093/intqhc/mzm029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Evaluating quality of patient care communication in integrated care settings: a mixed method approach
1 Roessingh Research and Development, Institute for Research in Rehabilitation Medicine and Technology, Enschede, The Netherlands
2 Roessingh Research and Development, Institute for Research in Rehabilitation Medicine and Technology, Enschede, The Netherlands
3 University of Twente, Department of Communication Studies, Faculty of Behavioural Sciences, Enschede, The Netherlands
4 University of Twente, School of Management and Governance, Enschede, The Netherlands
Address reprint requests to: Jitske Gulmans; Tel: +31-53-4875777; Fax: +31-53-4340849; E-mail: j.gulmans{at}rrd.nl
 |
Abstract |
|---|
 Top Abstract IntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
Background. Owing to the involvement of multiple professionals from various institutions, integrated care settings are prone to suboptimal patient care communication. To assure continuity, communication gaps should be identified for targeted improvement initiatives. However, available assessment methods are often one-sided evaluations not appropriate for integrated care settings.
Objective. We developed an evaluation approach that takes into account the multiple communication links and evaluation perspectives inherent to these settings. In this study, we describe this approach, using the integrated care setting of Cerebral Palsy as illustration.
Methods/Results. The approach follows a three-step mixed design in which the results of each step are used to mark out the subsequent step's focus. The first step patient questionnaire aims to identify quality gaps experienced by patients, comparing their expectancies and experiences with respect to patient–professional and inter-professional communication. Resulting gaps form the input of in-depth interviews with a subset of patients to evaluate underlying factors of ineffective communication. Resulting factors form the input of the final step's focus group meetings with professionals to corroborate and complete the findings.
Conclusions. By combining methods, the presented approach aims to minimize limitations inherent to the application of single methods. The comprehensiveness of the approach enables its applicability in various integrated care settings. Its sequential design allows for in-depth evaluation of relevant quality gaps. Further research is needed to evaluate the approach's feasibility in practice. In our subsequent study, we present the results of the approach in the integrated care setting of children with Cerebral Palsy in three Dutch care regions.
Keywords: cerebral palsy, communication, health care evaluation mechanisms, patient care management
|
Introduction |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
In literature, various terms and definitions are used in reference to integrated care. The essence though is similar: when separate agencies or individual professionals do not cover the complete range of patient care, they need to collaborate and coordinate their services in order to achieve continuity. Although the aims of integrated care are mostly similar (i.e. the provision of comprehensive, coordinated and continuous services [1]), broad differences exist in translating these aims in practice. In this study, we refer to ‘integrated care settings’ as settings in which a network of multiple professionals from various organizations is involved to meet each patient's care needs. Consequently, the level of integration may vary broadly, from merely ‘linkage’ (caregivers of one organization seek outside providers with special know-how and complementary care services while remaining within the context of existing, fragmented systems) to highly structured forms of coordination in which the full spectrum of care is managed by creating new organizational infrastructures [2].
Regardless of the level of integration, in order to achieve comprehensive, coordinated and continuous services, optimal patient care communication is indispensable. In this study, we approach patient care communication along two axes: between patients and providers and among providers. Whereas patient–provider communication is predominantly relational in nature, requiring ‘productive interactions’ between the patient/family and the health care team, inter-provider communication primarily involves effective and efficient information exchange across services and settings so that appropriate information reaches those who need it at the appropriate time. Given the involvement of multiple professionals, integrated care settings are prone to gaps in both axes of communication [3]. To assure continuity of care, it is imperative to identify these gaps in order to implement targeted improvement initiatives. However, available assessment methods are often one-sided evaluations not appropriate for integrated care settings, as we illustrate below. To identify communication gaps relevant to both patients and professionals, we developed an evaluation approach that takes into account the multiple communication links and evaluation perspectives inherent to integrated care settings. In this study, we describe this approach, using the complex integrated care setting of Cerebral Palsy as illustration (see Box 1).
| Box 1 Cerebral Palsy: a complex integrated care setting. Cerebral Palsy: a complex integrated care setting Cerebral Palsy (prevalence 1.5–2.5/1000 live births) is an umbrella term for impairments in posture- and/ or motor function as a result of perinatal disturbances in the development of the brain. Dependent on the affected parts of the brain, the impaired posture/ motor function can be accompanied by mental retardation, psychosocial problems, epilepsy, visual, hearing or speech impairments etcetera. To meet the differential care needs of each patient, multiple professionals from various institutions are involved, from (specialized) hospitals to primary care centres, from day-care to (special) education centres. To assure continuity of care coordination across these settings is essential, though in practice often affected by suboptimal patient care communication, both among providers as well as with patients and their family.
|
|
Shortcomings of available assessment methods |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
In order to find appropriate assessment methods for evaluating quality of communication in integrated care settings, we conducted a Pubmed search covering studies with abstracts published in English between 1 January 1990 and 31 January 2007. The following MeSH-terms were used: ‘(investigative techniques) and (communication barriers or interprofessional relations) and (primary health care or delivery of health care, integrated or chronic disease)’. The majority of the resulting 440 studies could be excluded after screening of titles. The abstracts of the remaining 76 studies were judged by two of the authors on the basis of the following inclusion criteria: (i) study aim evaluation of patient care communication and (ii) focus on communication across settings and (iii) description of used assessment methods.
In total, 26 studies [4–29] met the inclusion criteria. In Table 1, an overview is given for their focus, aim, methods and evaluation perspective. Although each study evaluated communication across settings, we found none of them used assessment methods appropriate for application in integrated care settings. Among the most important shortcomings were
- ‘Evaluation of only one communication link’, e.g. the communication between hospital specialists and general practitioners [7, 8, 10, 15, 16, 19, 24, 25, 27–29] or the communication between hospital specialists and primary care physicians [4, 6, 11, 12, 14, 18, 20, 22, 23, 26]. To evaluate patient care communication in integrated care settings, communication links across the whole network should be taken into account.
- ‘Focus on only one aspect of communication’, e.g. referral communication [4, 5, 10, 22, 26, 27] or discharge communication [6, 15, 16, 24, 25]. For a comprehensive evaluation, the broad spectrum of patient care communication should be taken into account, both inpatient and outpatient.
- ‘Inclusion of only one evaluation perspective’, e.g. the perspective of general practitioners [7, 8, 10, 13, 24, 25, 28, 29] or the perspective of primary care physicians [5, 18, 20, 22]. Although various studies included two evaluation perspectives [4, 11, 12, 14, 17, 19, 21, 23], for evaluation of communication in integrated care settings it is imperative to consider the perspective of patients and various involved professionals;
- ‘Limited scope of evaluation data’, e.g. either obtaining overall, quantitative data through surveys and/or text analysis [4–7, 10, 12, 15–18, 20–24, 26, 27, 29] or in-depth, qualitative data from interviews or focus group meetings [9, 13, 14, 19, 28]. For an optimal understanding of the research problem both overall quantitative as well as in-depth qualitative data are needed.
|
|
Towards an evaluation approach for integrated care settings |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
On the basis of these shortcomings, the evaluation of patient care communication in integrated care settings should incorporate:
- an operationalization of patient care communication attuned to integrated care settings;
- a focus on various communication links across settings;
- a quality evaluation from the perspectives of patients and professionals;
- an integration of quantitative and qualitative assessment methods.
Operationalization of communication attuned to integrated care settings
In this study, we approach patient care communication along two axes: between patients and providers and among providers. Whereas patient–provider communication is predominantly relational in nature, communication among providers primarily involves effective and efficient information exchange. Therefore, in our evaluation approach we address two aspects of patient care communication: (i) inter-professional information exchange with dimensions such as timeliness, accessibility and appropriate amount of exchanged information [30]; and (ii) patient–professional relational interactions with dimensions such as shared decision-making, empathy, openness and respect [31].
Focus on various communication links across settings
Given the multiple professionals that are involved in integrated care settings, our approach should include multiple patient–provider and inter-provider links. However, evaluation of the vast number of possible inter-provider links would be time consuming and practically impossible. Therefore, we propose to focus on links with professionals who are highly central to the care setting, in communication network theory also referred to as ‘star’-members [32]. In integrated care settings, this ‘star’-member usually is a primary care provider (PCP) given their ‘distinctive role in integrating the care that patients receive from within and outside of the primary care setting’ [33]. Dependent of the care setting, the PCP can be a family doctor, internist, paediatrician or geriatrist, or any other professional who takes care of the entire range of a person's basic health care needs over a prolonged period of time (see Box 2).
| Box 2 Multiple Communication links in Cerebral Palsy Care. Multiple communication links in Cerebral Palsy care Dependent on the life phase of patients with Cerebral Palsy, various professionals can fulfil the coordinating role of Primary Care Provider (PCP). In children with CP, the PCP usually is a paediatrician, paediatric neurologist, or rehabilitation physician/physiatrist. As highly central professionals in the care network, their communication links cross the integrated care network as a whole. Therefore, evaluation of inter-provider communication in the care of children with Cerebral Palsy should focus on communication links to- and from the child's PCP.
|
Quality evaluation from the perspectives of patients and professionals
Particularly in integrated care settings in which multiple professionals, disciplines and institutions are involved, the perspective of each professional is limited to the specific role they play in the care network. Patients on the other hand, come in contact with various professionals, disciplines and institutions, and thus are capable of providing feedback on the complete range of care. Consequently, we will use the patient perspective as central source of feedback in our approach.
In evaluation research of service quality from the client's perspective, the expectancies/experiences approach is often used [34]. Taking this approach as starting point in our evaluation, the concept of quality is operationalized as the degree to which patients' experiences meet their expectancies. A ‘quality gap’ is apparent when a patient's experiences do not match his/her expectancies with respect to a certain aspect.
Integration of quantitative and qualitative assessment methods
In the social and human sciences mixed method approaches are gaining increasingly attention because of their possibilities to optimize the potential of both quantitative and qualitative approaches [35]. By seeking convergence across different methods (known as ‘triangulation’) biases inherent to any single method can be neutralized. Further, the mixed method approach allows for a ‘sequential design’ in which the results from one method can be used to develop or focus the subsequent method.
|
Translation into a three-step mixed design approach |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
Translation of the above criteria resulted in the three-step mixed design approach presented in Table 2. As shown, the approach works as a ‘funnel’, in which the focus of each subsequent step is a derivative of specific outcomes of the previous step. As such, the approach aims to identify those aspects of communication most in need of improvement to both patients as well as involved professionals.
|
Relevant communication links in the integrated care setting
As mentioned, evaluation of the vast number of communication links in an integrated care setting would be time-consuming and practically impossible. Therefore, we need to determine relevant patient–provider and inter-provider links that should be included in the first step's patient questionnaire. In less complex integrated care settings, such as stroke, each patient follows a relatively similar care pathway. In these care settings, it often will be clear which care providers are involved and, accordingly, which patient provider and inter-provider links should be included. In complex care settings such as diabetes or cerebral palsy, however, heterogeneous care needs leads to a broad range of individual care pathways. As a result, multiple care providers are involved, during a large or short time period, for a majority or only a minority of patients. To yield aspects of improvement that are relevant for most patients, the three-steps evaluation approach should focus on communication links that occur in the care of the majority of patients. An objective way to determine these links is to perform a medical record review on the PCP's in- and outgoing cross-organizational correspondence, scoring the frequency of communication links. The proportion of patient records in which a link occurs as well as the frequency of that link's occurrence within each patient record determines the relative strength of each communication link. The strongest communication links derived from this analysis can subsequently be included in the first step patient questionnaire.
Step I: Quality evaluation through patient questionnaire
The aim of this step is to identify communication links in which patients experience quality gaps. Various patient questionnaires are available that evaluate overall quality of care and address patient care communication in separate items or subscales. Examples of validated measures include the Primary Care Assessment Survey [36] and the Measure of Processes of Care [37]. However, the communication items in these measures only focus on patients' overall experiences with communication and do not discriminate between various patient–provider and inter-provider links in the care setting. For the purpose of this evaluation step this distinction is essential. We therefore composed a patient questionnaire that evaluates patients' experiences and expectancies regarding the various patient–provider and inter-provider links in their care settings. Those links in which most patients experience quality gaps are used as an input for Step II.
Step II: In-depth interviews with subset of patients
To identify the factors that underlie the quality gaps, in-depth interviews are held with the patient subset that reported these gaps. A methodology that can be used to illuminate experiences and opinions of a small minority of respondents is the critical incidence technique, originally developed by Flanagan but since then applied in numerous studies to obtain concrete instances of effective and ineffective behaviour in any context [38]. In our approach, we primarily focus on examples of ineffective communication as these directly yield relevant aspects for improvement. The interviewer refers to gaps reported by the patient in the questionnaire and subsequently asks the patient to provide examples of situations in which he/she experienced these gaps. Each example is elaborated upon by posing predefined questions (i.e. what actually happened, who was involved, what led up to the situation, what were the consequences etc.). The aim of the interviews is not to obtain an exhaustive report about the origin of each individual communication problem, but to exceed the level of unique individual situations in search of themes applying to various patients and various experiences of one patient. These themes form the input of the final step of the evaluation approach.
Step III: Focus group meetings with involved professionals
The aim of this final evaluation step is to corroborate and complete the findings from the perspective of professionals. Hereto, a focus group approach is chosen, given its frequent application in multimethod strategies to interpret findings from other sources and to compare, challenge or support, but ultimately extend personal meanings and experiences [38]. Although there are no general standards to conduct focus groups, they often (i) use homogeneous strangers as participants; (ii) rely on high moderator involvement; (iii) have 6–10 participants per group; and (iv) have a total of 3–5 groups per project [39]. For the purpose of this step, the focus groups consist of professionals that represent disciplines involved in the suboptimal communication links that resulted from Step I. The aim of the discussion is 2-fold: (i) corroboration: do the professionals recognize the themes that emerged from the patient narratives? and (ii) completion: which additional factors do professionals experience in relation to these themes? Integrating the findings of the focus group meetings with those of the preceding in-depth interviews concludes the three-step sequential design. Together they form relevant aspects for targeted improvement initiatives.
|
Discussion |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
In contrast to available methods, the presented approach in this study evaluates patient care communication across the integrated care setting as a whole. By taking into account various communication links, evaluation perspectives and -methods, it forms a comprehensive approach that can be applied to a broad range of integrated care settings. What we need to consider, though, is whether this comprehensiveness does not come at the expense of the approach's feasibility in practice. A sequential design may in general be more time-consuming than the alternative ‘concurrent design’ in which multiple forms of data are collected all at once. On the other hand, a sequential design offers the possibility to first identify a subpopulation of relevant cases for subsequent in-depth evaluation. Also, the approach can be applied as a whole or in separate parts, dependent on the complexity of the studied integrated care setting and the existing information on quality of communication that is available in advance. In some settings, problematic communication links may be already known, leaving in-depth patient interviews and/or focus groups with professionals to identify underlying factors.
Another issue is the approach's validity. One of the utilities of mixed methods research is the possibility of internal validation through triangulation of data, i.e. comparing and complementing data as a means to confirm, cross-validate, or corroborate findings within a single study. In the presented three-steps sequential design, this comparison and completion of data is only relevant for the last two steps, given their mutual aim to evaluate underlying factors of experienced quality gaps. Therefore, we consider the approach's validity in an alternative context, i.e. the context of our predefined criteria with respect to what do we evaluate (i.e. operationalization of patient care communication in integrated care settings) and how do we evaluate it (i.e. rationale of a mixed method design). With respect to the first criterion (what do we evaluate), we chose an operationalization of patient care communication in terms of patient–provider relational interactions (with dimensions such as shared decision-making, empathy, openness and respect) and inter-provider information exchange (with dimensions such as timeliness, accessibility and appropriate amount of exchanged information). Indeed, patient–provider links encompass dimensions of information exchange as well (just as inter-provider links also encompass relational interactions); we based our focus on the context in which patient–provider and inter-provider links primarily occur. With respect to the second criterion (how do we evaluate), we chose a funnel approach in which the results of each step are used to mark out the subsequent step's focus.
From an improvement point of view, a gap is more relevant, when more patients and professionals experience it. Therefore, in Step I communication links are included that occur in the care of the majority of the patient population. And in Step II the links in which the most patients experience quality gaps are further evaluated.
To evaluate patient–provider and inter-provider links, we chose the patient perspective as central source of feedback. For patient–provider links, this seems logical as patients can report their direct experiences. With respect to inter-provider links, however, patients can only report indirect impressions of only a part of the total communication that takes place among professionals. Nevertheless, these indirect and incomplete impressions do provide insight in the core of inter-provider communication, namely its ultimate effects on the patient. The alternative (evaluation of inter-provider links from the PCP perspective) would inevitably result in overall experiences not related to individual patients, as evaluation of PCP's experiences regarding each of the various inter-provider links per individual patient would be impossible. Correspondingly, the aim of the critical incidence interviews is not to obtain an exhaustive report about the origin of each individual communication problem- indeed this would require chart-reviews and interviews with involved professionals as patients obviously cannot be aware of all aspects that led to the communication problem. The aim of the interviews is to exceed the level of unique individual situations in search of general themes that apply to various patients.
Dependent on the complexity of the integrated care setting, the 3-step mixed design approach is preceded by a network analysis to identify relevant links in the care setting. An objective method for this analysis is a medical record review on the PCP's in- and outgoing cross-organizational correspondence. We preferred an objective method to score the relative frequency of communication links, as subjective methods to (e.g. interviews with stakeholders) are susceptible to recall-bias. Finally, more information is needed regarding the minimal number of patients and professionals needed at each step to get a good picture. In step I, the minimal number of patients is hard to specify, as this would require power-calculations for which an estimated effect size is needed. This is complicated as integrated care settings differ substantially from one another and patient populations can be highly heterogeneous (especially in care settings like Cerebral Palsy). In step II, the subset of patients that are approached for in-depth interviews is a result of step I and thus variable in each evaluation. In studies on critical incidences, though, it is often mentioned that a saturation effect (i.e. no new incidents) when far more than 20 interviews are analysed. With respect to step III, focus groups are characterized by a small number of participants, often consisting of 6–10 participants per group [39].
In this study, we introduced a framework for evaluating patient care communication in integrated care settings, using the integrated care setting of Cerebral Palsy as an illustration. In our subsequent study, we apply the 3-step evaluation approach in this complex care setting, in order to gain insight in the added value and feasibility of the approach in practice.
|
References |
|---|
|
TopAbstractIntroductionShortcomings of available...Towards an evaluation approach...Translation into a three-step...DiscussionReferences |
|---|
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for The 21st Century (2001) Washington, DC: National Academy Press.
- van Raak A, Mur-Veeman I, Hardy B, et al. Integrated Care in Europe: Description and Comparison of Integrated Care in Six EU Countries (2003) Maarssen: Elsevier Gezondheidszorg.
- Weiner SJ, Barnet B, Cheng TL, et al. Processes for effective communication in primary care. Ann Intern Med (2005) 8:709–14.[Medline]
- Stille CJ, McLaughlin TJ, Primack WA, et al. Determinants and impact of generalist–specialist communication about pediatric outpatient referrals. Pediatrics (2006) 4:1341–9.
- Greene BR, Smith M, Allareddy V, et al. Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med (2006) 6.
- Helleso R. Information handling in the nursing discharge note. J Clin Nurs (2006) 1:11–21.
- Verdoux H, Cougnard A, Grolleau S, et al. How do general practitioners manage subjects with early schizophrenia and collaborate with mental health professionals? A postal survey in South-Western France. Soc Psychiatry Psychiatr Epidemiol (2005) 11:892–8.
- Farquhar MC, Barclay SI, Earl H, et al. Barriers to effective communication across the primary/secondary interface: examples from the ovarian cancer patient journey (a qualitative study). Eur J Cancer Care (Engl) (2005) 4:359–66.
- Bruce K, Suserud BO. The handover process and triage of ambulance-borne patients: the experiences of emergency nurses. Nurs Crit Care (2005) 4:201–9.
- Jiwa M, Coleman M, McKinley RK. Measuring the quality of referral letters about patients with upper gastrointestinal symptoms. Postgrad Med J (2005) 957:467–9.
- Satzinger W, Courte-Wienecke S, Wenng S, et al. Bridging the information gap between hospitals and home care services: experience with a patient admission and discharge form. J Nurs Manag (2005) 3:257–64.
- Stille CJ, Primack WA, Savageau JA. Generalist-subspecialist communication for children with chronic conditions: a regional physician survey. Pediatrics (2003) 6:1314–20.
- McNulty CA, Coleman T, Telfer-Brunton A, et al. How should laboratories communicate with primary care? Obtaining general practitioners' views. J Infect (2003) 2:99–103.
- Stille CJ, Korobov N, Primack WA. Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups. Ambul Pediatr (2003) 3:147–53.[CrossRef][Web of Science][Medline]
- Jansen JO, Grant IC. Communication with general practitioners after accident and emergency attendance: computer generated letters are often deficient. Emerg Med J (2003) 3:256–7.
- Foster DS, Paterson C, Fairfield G. Evaluation of immediate discharge documents–room for improvement? Scott Med J (2002) 4:77–9.
- Fairchild DG, Hogan J, Smith R, et al. Survey of primary care physicians and home care clinicians. J Gen Intern Med (2002) 4:253–61.
- Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med (2001) 9B:15S–20S.
- van der Kam WJ, Meyboom de Jong B, Tromp TF, et al. Effects of electronic communication between the GP and the pharmacist. The quality of medication data on admission and after discharge. Fam Pract (2001) 6:605–9.
- Barnes EA, Hanson J, Neumann CM, et al. Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy. J Clin Oncol (2000) 15:2902–7.
- Mainous AG, Gill JM, Zoller JS, et al. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med (2000) 5:446–50.
- Forrest CB, Glade GB, Baker AE, et al. Coordination of specialty referrals and physician satisfaction with referral care. Arch Pediatr Adolesc Med (2000) 5:499–506.
- Cox S. Improving communication between care settings. Prof Nurse (2000) 4:267–71.
- Paterson JM, Allega RL. Improving communication between hospital and community physicians. Feasibility study of a handwritten, faxed hospital discharge summary. Discharge Summary Study Group. Can Fam Physician (1999) 45:2893–9.[Web of Science][Medline]
- Bolton P, Mira M, Kennedy P, et al. The quality of communication between hospitals and general practitioners: an assessment. J Qual Clin Pract (1998) 4:241–7.
- Anderson MA, Helms LB. Comparison of continuing care communication. Image J Nurs Sch (1998) 3:255–60.
- Montalto M, Harris P, Rosengarten P. Impact of general practitioners' referral letters to an emergency department. Aust Fam Physician (1994) 7:1320–1. 1324–5, 1328.
- Wood ML. Communication between cancer specialists and family doctors. Can Fam Physician (1993) 39:49–57.[Web of Science][Medline]
- Branger PJ, van der Wouden JC, Schudel BR, et al. Electronic communication between providers of primary and secondary care. BMJ (1992) 6861:1068–70.
- Lee YW, Strong DM, Kahn BK, et al. AIMQ: a Methodology for Information Quality Assessment. Inf Manage (2003) 2:133–146.
- Gerteis M, Edgman-Levitan S, Walker JD, et al. What patients really want. Health Manage Q (1993) 3:2–6.
- Monge PR, Contractor NS. Theories of Communication Networks (2003) Oxford: Oxford University Press.
- Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med (2003) 3:248–55.
- Zeitahml VA, Parasuraman A. Service Quality (2004) Cambridge, MA: Marketing Science Institute.
- Tashakkori A, Teddlie C. Handbook of Mixed Methods in Social and Behavioral Research (2003) Thousand Oaks: Sage.
- Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care (1998) 5:728–39.
- King GA, Rosenbaum PL, King SM. Evaluating family-centred service using a measure of parents' perceptions. Child Care Health Dev (1997) 1:47–62.
- Hargie O, Tourish D. Handbook of communication audits for organisations (2000) London: Routledge.
- Morgan DL. Focus groups as qualitative research (1997) Thousand Oaks, Calif: Sage.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  J. Gulmans, M. M. R. Vollenbroek-Hutten, J. E. W. C. Van Gemert-Pijnen, and W. H. Van Harten Evaluating patient care communication in integrated care settings: application of a mixed method approach in cerebral palsy programs Int. J. Qual. Health Care, February 1, 2009; 21(1): 58 - 65. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||