Andrew Thompson

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

3
Current context
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)

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

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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

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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

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Current understanding of patient satisfaction and
its determinants
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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.
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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.
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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.
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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

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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

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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

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Examples of high/low global scores
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Comparing dimensions
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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.
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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

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Measurement issues
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Which patients?

• Specific services
• Sub-populations e.g. socio-demography,
  illness/condition, geographical
• Complainants
• Problems
• - exclusion of important groups
• - appropriate attribution of responsibility

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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 didnt really care about
  me at all

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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

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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

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Problems in satisfaction measures 2

• Methodological
• direct vs indirect evaluation
• general vs specific aspects
• weak measures non-discriminating
• distorted measures skewed
• simplifying analytical assumption

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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

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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

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Potential for agency
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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

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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.
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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

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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

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Conclusions
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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

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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

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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

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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

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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