1 Measuring Patients’ Experience of Hospital Care Angela Coulter Picker Institute Europe

2 Three Perspectives on Quality Professional: technical competence, clinical outcomes Professional: technical competence, clinical outcomes Management: cost-effectiveness, risk management, service development Management: cost-effectiveness, risk management, service development Patient: access, responsiveness, communication, symptom relief, health status, quality-of-life Patient: access, responsiveness, communication, symptom relief, health status, quality-of-life

3 Why measure patients’ experience of health care? To assist local quality improvement To assist local quality improvement For national performance assessment For national performance assessment For strategic policy-making For strategic policy-making To build public confidence To build public confidence To inform purchasers To inform purchasers To inform patients To inform patients To compare health systems To compare health systems

4 Measuring patients’ experience Focus on recent personal experience Focus on recent personal experience Ask patients about what is important to them (focus groups and interviews) Ask patients about what is important to them (focus groups and interviews) Ask patients to report on what happened, NOT how satisfied they were (surveys) Ask patients to report on what happened, NOT how satisfied they were (surveys) Feed back actionable results Feed back actionable results

5 Overall, how would you rate the care you received?

6 Reporting Questions A&E care disorganised38% A&E care disorganised38% Reason for delay not explained6% Reason for delay not explained6% Staff gave conflicting information23% Staff gave conflicting information23% Doctors talked as if I wasn’t there30% Doctors talked as if I wasn’t there30% Had to wait too long for pain medicine9% Had to wait too long for pain medicine9% Risks and benefits not discussed 24% Risks and benefits not discussed 24% Not told when to resume activities60% Not told when to resume activities60%

7 Picker Surveys of Patients’ Experience Access to care Access to care Respect for patients’ preferences Respect for patients’ preferences Co-ordination of care Co-ordination of care Information and education Information and education Physical comfort Physical comfort Emotional support Emotional support Involvement of family and friends Involvement of family and friends Continuity and transition Continuity and transition

8 Questionnaire Development Define scope of survey Define scope of survey Review literature Review literature Focus groups – professionals and patients Focus groups – professionals and patients Cognitive interviews with patients Cognitive interviews with patients Two stage pilot testing Two stage pilot testing Validation tests and scale development Validation tests and scale development

9 Implementation Random samples of patients Random samples of patients Detailed self completion questionnaires Detailed self completion questionnaires Mailed 2 – 4 weeks after discharge Mailed 2 – 4 weeks after discharge Two reminders to non-responders Two reminders to non-responders Response rates of % Response rates of % Problem scores and dimensions Problem scores and dimensions

10 Patient Safety: AHRQ Guidelines Active participation of patients Active participation of patients Information sharing Information sharing Allergies and adverse reactions to drugs Allergies and adverse reactions to drugs Understanding instructions Understanding instructions Cleanliness Cleanliness Discharge information and treatment plan Discharge information and treatment plan

11 Picker Surveys of Patients’ Experience

12 Picker Surveys of Patients’ Experience

13 Picker Surveys of Patients’ Experience

14 NHS Survey of Patients with Coronary Heart Disease Sampled patients with diagnosis of CHD from hospital records Sampled patients with diagnosis of CHD from hospital records Names, addresses from 194 NHS Trusts in England Names, addresses from 194 NHS Trusts in England Sample size 112,000 Sample size 112,000 Postal questionnaire Postal questionnaire 84,300 completed questionnaires 84,300 completed questionnaires Response rate 74% Response rate 74%

15 NHS Patients Survey (CHD): Information and Communication

16 NHS Patients Survey (CHD): Coordination and Continuity

17 NHS Patients Survey (CHD): Hospital Environment 35% on mixed sex ward (5-76%) 35% on mixed sex ward (5-76%) 38% bothered by noise (26-54%) 38% bothered by noise (26-54%) 35% said toilets/bathrooms not clean (16- 69%) 35% said toilets/bathrooms not clean (16- 69%) 36% said not enough nurses on duty (23- 54%) 36% said not enough nurses on duty (23- 54%)

18 Did not feel sufficiently involved in decisions about care % National Surveys of NHS Patients. Coronary Heart Disease 1999 (n=84,500)

19 NHS Patients Survey (CHD): Discharge and Transition 34% no written information about recovery (5-53%) 34% no written information about recovery (5-53%) 39% no advice on prevention (10-55%) 39% no advice on prevention (10-55%) 32% no advice on resuming normal activities (10-53%) 32% no advice on resuming normal activities (10-53%) 31% said home circumstances not taken into account (18-45%) 31% said home circumstances not taken into account (18-45%)

20 Patient Surveys Should Be: Relevant to patients’ concerns Relevant to patients’ concerns Relevant to policy goals Relevant to policy goals Actionable Actionable Timely Timely Comparable Comparable Methodologically sound Methodologically sound Accessible Accessible

21 National vs. Local Surveys Local surveys Locally ‘owned’ Locally ‘owned’ Locally relevant Locally relevant Shorter time-scale Shorter time-scale National surveys Consistent methodology Consistent methodology Cost-effective Cost-effective Independent of hospital Independent of hospital

22 A Third Way: Locally-organised Surveys with National Standards Core set of validated questions Core set of validated questions Implementation standards and manual Implementation standards and manual Data analysis tool kit Data analysis tool kit National benchmarks National benchmarks Flexibility to add local questions Flexibility to add local questions

23 Conclusions Patient feedback is a key element of quality improvement Patient feedback is a key element of quality improvement Surveys of patient experience are more useful than patient satisfaction Surveys of patient experience are more useful than patient satisfaction Patient surveys can help to improve safety standards Patient surveys can help to improve safety standards National benchmarks can stimulate improvements National benchmarks can stimulate improvements