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

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

2. Content • Current context • policy, evolution and health care • Current understanding of patient satisfaction and its determinants • Measurement issues • Potential for agency • professionals, patients/relatives, society • Conclusions Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

3. Current context… Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

4. Policy and politics • Consensus on patient involvement in definitions, development and management of quality of health care • Focus on patient-centredness • Continuum of political control: • central command and control • laissez-faire • centralised regulatory frameworks (3rd Way) Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

5. Evolution of patient-centredness • Increased lay knowledge and self-help • Increased awareness of professional fallibility and diagnostic uncertainty • Rise in scepticism about medicine/science • Awareness of wider influences on health • Shift in focus from acute to chronic conditions • Wide variation in clinical practice • Pressure to increase accountability • Pressure to democratise public health systems • Shift from objective to subjective medicine Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

6. What is unique about health care? • Often long-term duration of interaction • Heightened emotional levels - anxiety, fear, pain • Purpose is to meet needs – rarely trivial • Aim is to reduce demand via effectiveness • Wide and increasing gap between professional technical competence and patient understanding • Public and private lives ‘laid bare’ • ‘Boundary-open’/blurred demarcation between patient and practitioner (co-production) • Ambiguous outcomes for patients and professionals • Extraordinary experience • rare and intense emotions • difficult to describe (personal/abstract) • ‘triumph’ can cause positive post-hoc re-evaluation Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

7. Why is patient satisfaction important? • Public accountability • Quality improvement • Macro-level: • system performance management • benchmarking • competition/contestability through markets • Micro-level: • feedback to professionals and managers • acceptability of processes / social model of health Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

8. Current understanding of patient satisfaction and its determinants… Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

9. A 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. Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

10. A theoretical model of patient satisfaction COGNITIVE AFFECTIVE Adapted from Oliver RL (1993). Cognitive, affective, and attribute bases of the satisfaction response. J Cons Res, 20, 418. Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

11. Problems of expectations • Assumed rationality of utility-maximising individuals (economics, marketing) • Unformed, imprecise, manipulable • Different meanings • Ideal – what we would like to happen, irrespective of reality • Normative – what we believe ought to happen • Predicted – what 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. Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

12. What are the determinants? - patient specific • Expectations – lack of evidence • Health status • poorer health, more negative • longer length of stay, more negative • repeat patients, more negative • Socio-demography • Age – consistent positive relationship (adults) - unclear amongst children (and parents of young) • Gender – inconclusive / mixed results • Education – more educated can be more critical • Ethnicity – inconclusive / mixed results • Socio-economic status – inconsistent effect • Married/co-habiting – more positive on human aspects, less positive on physical aspects Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

13. What are the determinants? - survey logistics • Responding alone (without help), more positive • Significant others – often more negative • Immediate responders (1st mailing), more positive • later responders tend to be older, widowed and needing help to answer Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

14. One or several dimensions? • Global satisfaction • Limited relationship to health care experience • May be a measure of quality of life, rather than quality of health care • Specifics show multidimensional picture • Varies according to health service • Relationship with practitioners, including information/communication, is key Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

15. Examples of high/low global scores Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

16. Comparing dimensions Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

17. Comparative dimensions of service satisfaction – example of Scotland Bikker AP and Thompson AGH (2006). Predicting and comparing patient satisfaction in four different modes of health care across a nation. Social Science & Medicine, 63, 1671-1683. Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

18. Specific issues for population groups – examples from UK • Women • empathy; professional co-ordination; facilities for children; screening; emotional care • Elderly • dignity/independence; home care; health promotion • Children • maintaining family contact; education; involvement • Disabled • physical access; communication; staff identification • Ethnic minorities • information/communication; cultural awareness of staff • Rural • access; service centralisation; choice vs. good local facilities Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

19. Measurement issues… Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

20. Which patients? • Specific services • Sub-populations; e.g. socio-demography, illness/condition, geographical • Complainants Problems: - exclusion of important groups - appropriate attribution of responsibility Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

21. Examples of question types • Reports • Were you ever bothered by noise from hospital staff? YES/NO • Ratings – direct and indirect forms • I am very satisfied with the quality of nursing care Strongly agree / Agree / Disagree / Strongly disagree • The care from the nurses was kind, gentle and sympathetic at all times … I felt that the nurses didn’t really care about me at all Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

22. Reports or ratings? • Problems with measuring satisfaction • lack of an adequate coherent theory • lack of utility for quality improvement • high reported levels and lack of variation This has led some to abandon satisfaction in favour of patient reports Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

23. Problems in satisfaction measures : 1 • Theoretical • concentration on cognitive aspects • assumption of continuum from satisfaction to dissatisfaction • Epistemological • scientific reliability and validity • context and interaction between variables Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

24. Problems in satisfaction measures : 2 • Methodological • direct vs indirect evaluation • general vs specific aspects • weak measures – non-discriminating • distorted measures – skewed • simplifying analytical assumption Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

25. Problems with patient reports • Assumption of objectivity • scientific/bio-medical objectivity vs humanistic/social scientific subjectivity • Who decides on acceptability, if not patients? • patient-centredness arguably gives primary role to patients Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

26. Other issues of measurement • Source of questions and response options (content validity) • Acquiescence Response Set • occurs in half the cases in experimental studies – older, sicker, less educated, poorer • Administration of surveys • Interviews, self-completion • Non-response and use of reminders/incentives • Use of proxies • Timing – memory effects, outcome effects, critical distance • Independence of surveyor • General population vs service-specific • Individual vs group views Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

27. Potential for agency… Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

28. What can professionals do? • Understand the importance of patient involvement in their own health and health care, as co-producers, not consumers • Prioritise what is important to patients and their informal carers, whilst maintaining a critical professional view • Maintain what is perceived to be good and improve what needs improving • Involve all staff from the beginning • Draw comparisons over time and with others Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

29. The good and the not so good- priorities for attention Thompson A (1986). The soft approach to quality of hospital care. Int J Quality and Reliability Management, 3(3), 57-65. Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

30. What can patients and relatives/family/significant others do? • Engage in dialogue with professionals to share information and, if desired, to share decisions • Seek help from voluntary and community groups, as well as providing them with feedback Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

31. What can society do? • Voluntary and community groups can train professionals in ways of communication in relation to specific conditions or population groups • Provide accessible and appropriate educational resources to enable patients and their families to be involved as much as they wish to be • Influence policy and planning to require patient-centred working practices Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

32. Conclusions… Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

33. Reasons against patient satisfaction… • Not competent to judge • What they want might be harmful to their health • Being a patient may distort judgement • Memory tends to be partial and distorted • Encourages negative views/dissatisfaction • Promotes popularity rather than quality • Dependency leads to a reluctance to be candid • High satisfaction whatever the treatment • Cannot measure subjective feelings validly and reliably • Creates unrealistic expectations • PR exercise to create illusion of participation • Shifts responsibility for difficult decisions to the public Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

34. Reasons for patient satisfaction… • It is itself a desirable outcome • It is directly related to other positive outcomes • Patients have a wider view than professionals • Often patients are in the best position to judge • It can help to choose the best method of care • It is an expression of patient autonomy • As payers the public have the right to be heard • It is a democratic right in a public service • It is a form of community participation • It helps to counteract medical hegemony • It is a measure of organisational/professional performance • Organisational competition is won through it Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

35. Does it improve quality of care? • Lack of much evidence of positive effects • Lack of organisational strategy • Lack of vision as to its value • Problems of interpretation and ease of use • Mistrust of results • Unsure about how much weight to give it • Insufficient investment • Lack of commitment to external measures • Interest often limited to specific issues • Need for political commitment to supporting patients as co-producers of health care • Need for partnership between patients, informal carers, voluntary/community groups and professionals to improve quality of care Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

36. Horses for courses • Micro-level: service quality improvement • professionals and managers need to know where to focus (ratings) and how to improve services (reports) • need information on what is important, as well as the most satisfying/dissatisfying • Macro-level: public accountability • need for a parsimonious set of indicators • evidence (limited) of superiority of ratings Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006

37. Concluding comments • To decide on the value of patient judgements, there is a need to know: • causes of satisfaction and dissatisfaction • meanings and importance of health care • In attempting to solve apparent methodological problems, a focus on reports alone raises problems of an ethical and political nature • Need to embrace subjectivity and work to understand it to create patient-centred services and a coherent theory of patient satisfaction Andrew Thompson What is patient satisfaction? VII Meeting of INGID, Budapest, Hungary. 5th October 2006