Andrew Thompson What is patient satisfaction - and what can we do about it?

Andrew ThompsonAndrew Thompson

What is patient satisfactionWhat is patient satisfaction- and what can we do about it?- and what can we do about it?

Andrew ThompsonAndrew Thompson What is patient satisfaction?What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. VII Meeting of INGID, Budapest, Hungary. 55thth October 2006 October 2006

ContentContent

Current contextCurrent context policy, evolution and health carepolicy, evolution and health care

Current understanding of patient Current understanding of patient satisfaction and its determinantssatisfaction and its determinants

Measurement issuesMeasurement issues Potential for agencyPotential for agency

professionals, patients/relatives, societyprofessionals, patients/relatives, society ConclusionsConclusions


Current context…Current context…


Policy and politicsPolicy and politics

Consensus on patient involvement in Consensus on patient involvement in definitions, development and definitions, development and management of quality of health caremanagement of quality of health care

Focus on patient-centrednessFocus on patient-centredness Continuum of political control:Continuum of political control:

central command and controlcentral command and control laissez-fairelaissez-faire centralised regulatory frameworks (3centralised regulatory frameworks (3rdrd Way) Way)


Evolution of patient-centrednessEvolution of patient-centredness

Increased lay knowledge and self-helpIncreased lay knowledge and self-help Increased awareness of professional fallibility Increased awareness of professional fallibility

and diagnostic uncertaintyand diagnostic uncertainty Rise in scepticism about medicine/scienceRise in scepticism about medicine/science Awareness of wider influences on healthAwareness of wider influences on health Shift in focus from acute to chronic conditionsShift in focus from acute to chronic conditions Wide variation in clinical practiceWide variation in clinical practice Pressure to increase accountabilityPressure to increase accountability Pressure to democratise public health systemsPressure to democratise public health systems Shift from objective to subjective medicineShift from objective to subjective medicine


What is unique about health care?What is unique about health care?

Often long-term duration of interactionOften long-term duration of interaction Heightened emotional levels - Heightened emotional levels - anxiety, fear, painanxiety, fear, pain Purpose is to meet needs – Purpose is to meet needs – rarely trivialrarely trivial Aim is to reduce demand via effectivenessAim is to reduce demand via effectiveness Wide and increasing gap between professional Wide and increasing gap between professional

technical competence and patient understandingtechnical competence and patient understanding Public and private lives ‘laid bare’Public and private lives ‘laid bare’ ‘‘Boundary-open’/blurred demarcation between patient Boundary-open’/blurred demarcation between patient

and practitioner (and practitioner (co-productionco-production)) Ambiguous outcomes for patients and professionalsAmbiguous outcomes for patients and professionals Extraordinary experienceExtraordinary experience

rare and intense emotionsrare and intense emotions difficult to describe (personal/abstract)difficult to describe (personal/abstract) ‘‘triumph’ can cause positive post-hoc re-evaluationtriumph’ can cause positive post-hoc re-evaluation


Why is patient satisfaction important?Why is patient satisfaction important?

Public accountabilityPublic accountability Quality improvementQuality improvement

Macro-level:Macro-level: system performance managementsystem performance management benchmarkingbenchmarking competition/contestability through marketscompetition/contestability through markets

Micro-level:Micro-level: feedback to professionals and managersfeedback to professionals and managers acceptability of processes / social model of healthacceptability of processes / social model of health


Current understanding of patient Current understanding of patient satisfaction and its determinants…satisfaction and its determinants…


A theoretical model of patient viewsA theoretical model of patient views

Perneger TV (2004). Adjustment for patient characteristics in satisfaction surveys, International Journal for Quality in Health Care, 16 (6), 433-435.


A theoretical model of patient A theoretical model of patient satisfactionsatisfaction

Expectations

Disconfirmation

Satisfaction

Emotions

Attributionof cause

Equity

Perceived attributeperformance

COGNITIVE

AFFECTIVE

Adapted from Oliver RL (1993). Cognitive, affective, and attribute bases of the satisfaction response. J Cons Res, 20, 418.


Problems of expectationsProblems of expectations

Assumed rationality of utility-maximising Assumed rationality of utility-maximising individuals (economics, marketing)individuals (economics, marketing)

Unformed, imprecise, manipulableUnformed, imprecise, manipulable Different meaningsDifferent meanings

Ideal – Ideal – what we would like to happen, what we would like to happen, irrespective of realityirrespective of reality

Normative – Normative – what we believe ought to happenwhat we believe ought to happen Predicted – Predicted – what we really think will happenwhat we really think will happen

Thompson AGH and Suñol R (1995). Expectations as determinants of patient satisfaction. Int J Qual Health Care, 7(2), 127-141.


What are the determinants?What are the determinants? - patient specific - patient specific Expectations – Expectations – lack of evidencelack of evidence Health statusHealth status

poorer health, more negativepoorer health, more negative longer length of stay, more negativelonger length of stay, more negative repeat patients, more negativerepeat patients, more negative

Socio-demographySocio-demography Age – Age – consistent positive relationship (adults)consistent positive relationship (adults)

- unclear amongst children (and parents of young)- unclear amongst children (and parents of young) Gender – Gender – inconclusive / mixed resultsinconclusive / mixed results Education – Education – more educated can be more criticalmore educated can be more critical Ethnicity – Ethnicity – inconclusive / mixed resultsinconclusive / mixed results Socio-economic status – Socio-economic status – inconsistent effectinconsistent effect Married/co-habiting – Married/co-habiting – more positive on human aspects, less more positive on human aspects, less

positive on physical aspectspositive on physical aspects


What are the determinants?What are the determinants? - survey logistics - survey logistics

Responding alone (without help), more Responding alone (without help), more positivepositive

Significant others – often more negativeSignificant others – often more negative Immediate responders (1Immediate responders (1stst mailing), more mailing), more

positivepositive later responders tend to be older, widowed later responders tend to be older, widowed

and needing help to answerand needing help to answer


One or several dimensions?One or several dimensions?

Global satisfactionGlobal satisfaction Limited relationship to health care experienceLimited relationship to health care experience May be a measure of quality of life, rather May be a measure of quality of life, rather

than quality of health carethan quality of health care Specifics show multidimensional pictureSpecifics show multidimensional picture

Varies according to health serviceVaries according to health service Relationship with practitioners, including Relationship with practitioners, including

information/communication, is keyinformation/communication, is key


Examples of high/low global scoresExamples of high/low global scores


Comparing dimensionsComparing dimensions


Comparative dimensions of service Comparative dimensions of service satisfaction – satisfaction – example of Scotlandexample of Scotland

Factor

1 2 3 4

General Practice

Interpersonal care and information

Physical facilities

Time Access

Domiciliary care


Time

Outpatients


Physical facilities

Access

Inpatients


Quality of food

Physical facilities

Access

Bikker AP and Thompson AGH (2006). Predicting and comparing patient satisfaction in four differentmodes of health care across a nation. Social Science & Medicine, 63, 1671-1683.


Specific issues for population groups Specific issues for population groups – – examples from UKexamples from UK WomenWomen

empathy; professional co-ordination; facilities for children; empathy; professional co-ordination; facilities for children; screening; emotional carescreening; emotional care

ElderlyElderly dignity/independence; home care; health promotiondignity/independence; home care; health promotion

ChildrenChildren maintaining family contact; education; involvementmaintaining family contact; education; involvement

DisabledDisabled physical access; communication; staff identificationphysical access; communication; staff identification

Ethnic minoritiesEthnic minorities information/communication; cultural awareness of staffinformation/communication; cultural awareness of staff

RuralRural access; service centralisation; choice vs. good local facilitiesaccess; service centralisation; choice vs. good local facilities


Measurement issues…Measurement issues…


Which patients?Which patients?

Specific servicesSpecific services Sub-populations; e.g. socio-demography, Sub-populations; e.g. socio-demography,

illness/condition, geographicalillness/condition, geographical ComplainantsComplainants

Problems:Problems:- exclusion of important groups- exclusion of important groups- appropriate attribution of responsibility- appropriate attribution of responsibility


Examples of question typesExamples of question types

ReportsReports Were you ever bothered by noise from hospital staff?Were you ever bothered by noise from hospital staff?

YES/NOYES/NO

Ratings – Ratings – direct and indirect formsdirect and indirect forms

I am very satisfied with the quality of nursing careI am very satisfied with the quality of nursing careStrongly agree / Agree / Disagree / Strongly Strongly agree / Agree / Disagree / Strongly

disagreedisagree

The care from the nurses was kind, gentle and sympathetic The care from the nurses was kind, gentle and sympathetic at all timesat all times……I felt that the nurses didn’t really care about me at allI felt that the nurses didn’t really care about me at all


Reports or ratings?Reports or ratings?

Problems with measuring satisfactionProblems with measuring satisfaction lack of an adequate coherent theorylack of an adequate coherent theory lack of utility for quality improvementlack of utility for quality improvement high reported levels and lack of variationhigh reported levels and lack of variation

This has led some to abandon satisfaction This has led some to abandon satisfaction in favour of patient reportsin favour of patient reports


Problems in satisfaction measures : 1Problems in satisfaction measures : 1

TheoreticalTheoretical concentration on cognitive aspectsconcentration on cognitive aspects assumption of continuum from satisfaction assumption of continuum from satisfaction

to dissatisfactionto dissatisfaction

EpistemologicalEpistemological scientific reliability and validityscientific reliability and validity context and interaction between variablescontext and interaction between variables


Problems in satisfaction measures : 2Problems in satisfaction measures : 2

MethodologicalMethodological direct vs indirect evaluationdirect vs indirect evaluation general vs specific aspectsgeneral vs specific aspects weak measures – weak measures – non-discriminatingnon-discriminating distorted measures – distorted measures – skewedskewed simplifying analytical assumptionsimplifying analytical assumption


Problems with patient reportsProblems with patient reports

Assumption of objectivityAssumption of objectivity scientific/bio-medical objectivity vs scientific/bio-medical objectivity vs

humanistic/social scientific subjectivityhumanistic/social scientific subjectivity

Who decides on acceptability, if not Who decides on acceptability, if not patients?patients? patient-centredness arguably gives primary patient-centredness arguably gives primary

role to patientsrole to patients


Other issues of measurementOther issues of measurement

Source of questions and response options Source of questions and response options (content (content validity)validity)

Acquiescence Response SetAcquiescence Response Set occurs in half the cases in experimental studies – older, sicker, occurs in half the cases in experimental studies – older, sicker,

less educated, poorerless educated, poorer Administration of surveysAdministration of surveys

Interviews, self-completionInterviews, self-completion Non-response and use of reminders/incentivesNon-response and use of reminders/incentives Use of proxiesUse of proxies Timing – memory effects, outcome effects, critical distanceTiming – memory effects, outcome effects, critical distance Independence of surveyorIndependence of surveyor

General population vs service-specificGeneral population vs service-specific Individual vs group viewsIndividual vs group views


Potential for agency…Potential for agency…


What can professionals do?What can professionals do?

Understand the importance of patient Understand the importance of patient involvement in their own health and health involvement in their own health and health care, as care, as co-producers, co-producers, not not consumersconsumers

Prioritise what is important to patients and Prioritise what is important to patients and their informal carers, whilst maintaining a their informal carers, whilst maintaining a critical professional viewcritical professional view

Maintain what is perceived to be good and Maintain what is perceived to be good and improve what needs improvingimprove what needs improving

Involve all staff from the beginningInvolve all staff from the beginning Draw comparisons over time and with othersDraw comparisons over time and with others


The good and the not so goodThe good and the not so good- - priorities for attentionpriorities for attentionBest aspectsBest aspects weightweight rankrank Aspects in need of Aspects in need of

most improvementmost improvementweightweight

Nursing careNursing care 23%23% 11 FoodFood 14%14%

Doctors’ careDoctors’ care 18%18% 22 Things to do in wardThings to do in ward 13%13%

CleanlinessCleanliness 7%7% 33 InformationInformation 7%7%

Relationships Relationships with staffwith staff

7%7% 44 TemperatureTemperature 6%6%

Care from other Care from other cliniciansclinicians

5%5% 55 Ward facilitiesWard facilities 6%6%

Visiting Visiting arrangementsarrangements

5%5% 66 SleepSleep

Noise LevelsNoise Levels

6%6%

6%6%

Relationships Relationships with patientswith patients

5%5% 77 DecorDecor 6%6%

Thompson A (1986). The soft approach to quality of hospital care. Int J Quality and Reliability Management, 3(3), 57-65.


What can patients and What can patients and relatives/family/significant others do?relatives/family/significant others do?

Engage in dialogue with professionals Engage in dialogue with professionals to share information and, if desired, to to share information and, if desired, to share decisionsshare decisions

Seek help from voluntary and Seek help from voluntary and community groups, as well as providing community groups, as well as providing them with feedbackthem with feedback


What can society do?What can society do?

Voluntary and community groups can train Voluntary and community groups can train professionals in ways of communication in professionals in ways of communication in relation to specific conditions or population relation to specific conditions or population groupsgroups

Provide accessible and appropriate Provide accessible and appropriate educational resources to enable patients and educational resources to enable patients and their families to be involved as much as they their families to be involved as much as they wish to bewish to be

Influence policy and planning to require Influence policy and planning to require patient-centred working practicespatient-centred working practices


Conclusions…Conclusions…


Reasons against patient satisfaction…Reasons against patient satisfaction…

Not competent to judgeNot competent to judge What they want might be harmful to their healthWhat they want might be harmful to their health Being a patient may distort judgementBeing a patient may distort judgement Memory tends to be partial and distortedMemory tends to be partial and distorted Encourages negative views/dissatisfactionEncourages negative views/dissatisfaction Promotes popularity rather than qualityPromotes popularity rather than quality Dependency leads to a reluctance to be candidDependency leads to a reluctance to be candid High satisfaction whatever the treatmentHigh satisfaction whatever the treatment Cannot measure subjective feelings validly and reliablyCannot measure subjective feelings validly and reliably Creates unrealistic expectationsCreates unrealistic expectations PR exercise to create illusion of participationPR exercise to create illusion of participation Shifts responsibility for difficult decisions to the publicShifts responsibility for difficult decisions to the public


Reasons for patient satisfaction…Reasons for patient satisfaction…

It is itself a desirable outcomeIt is itself a desirable outcome It is directly related to other positive outcomesIt is directly related to other positive outcomes Patients have a wider view than professionalsPatients have a wider view than professionals Often patients are in the best position to judgeOften patients are in the best position to judge It can help to choose the best method of careIt can help to choose the best method of care It is an expression of patient autonomyIt is an expression of patient autonomy As payers the public have the right to be heardAs payers the public have the right to be heard It is a democratic right in a public serviceIt is a democratic right in a public service It is a form of community participationIt is a form of community participation It helps to counteract medical hegemonyIt helps to counteract medical hegemony It is a measure of organisational/professional It is a measure of organisational/professional

performanceperformance Organisational competition is won through itOrganisational competition is won through it


Does it improve quality of care?Does it improve quality of care?

Lack of much evidence of positive effectsLack of much evidence of positive effects Lack of organisational strategyLack of organisational strategy Lack of vision as to its valueLack of vision as to its value Problems of interpretation and ease of useProblems of interpretation and ease of use Mistrust of resultsMistrust of results Unsure about how much weight to give itUnsure about how much weight to give it Insufficient investmentInsufficient investment Lack of commitment to external measuresLack of commitment to external measures Interest often limited to specific issuesInterest often limited to specific issues

Need for political commitment to supporting patients as Need for political commitment to supporting patients as co-producers of health careco-producers of health care

Need for partnership between patients, informal carers, Need for partnership between patients, informal carers, voluntary/community groups and professionals to voluntary/community groups and professionals to improve quality of careimprove quality of care


Horses for coursesHorses for courses

Micro-level:Micro-level: service quality improvementservice quality improvement professionals and managers need to know professionals and managers need to know

where to focus (ratings) and how to improve where to focus (ratings) and how to improve services (reports)services (reports)

need information on what is important, as well need information on what is important, as well as the most satisfying/dissatisfyingas the most satisfying/dissatisfying

Macro-level:Macro-level: public accountabilitypublic accountability need for a parsimonious set of indicatorsneed for a parsimonious set of indicators evidence (limited) of superiority of ratingsevidence (limited) of superiority of ratings


Concluding commentsConcluding comments

To decide on the value of patient judgements, To decide on the value of patient judgements, there is a need to know:there is a need to know: causes of satisfaction and dissatisfactioncauses of satisfaction and dissatisfaction meanings and importance of health caremeanings and importance of health care

In attempting to solve apparent methodological In attempting to solve apparent methodological problems, a focus on reports alone raises problems, a focus on reports alone raises problems of an ethical and political natureproblems of an ethical and political nature

Need to embrace subjectivity and work to Need to embrace subjectivity and work to understand it to create patient-centred services understand it to create patient-centred services and a coherent theory of patient satisfactionand a coherent theory of patient satisfaction

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Andrew Thompson What is patient satisfaction - and what can we do about it?