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

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

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

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

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

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

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

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

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

10. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 A theoretical model of patient satisfaction Expectations Disconfirmation Satisfaction Emotions Attribution of cause Equity Perceived attribute performance COGNITIVE AFFECTIVE Adapted from Oliver RL (1993). Cognitive, affective, and attribute bases of the satisfaction response. J Cons Res, 20, 418.

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

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

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

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

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

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

17. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 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.

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

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

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

21. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 Examples of question types Reports Reports Were you ever bothered by noise from hospital staff? YES/NO Were you ever bothered by noise from hospital staff? YES/NO Ratings – direct and indirect forms Ratings – direct and indirect forms I am very satisfied with the quality of nursing care 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 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

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

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

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

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

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

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

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

29. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 The good and the not so good - priorities for attention Best aspects weightrank Aspects in need of most improvement weight Nursing care 23%1Food14% Doctors’ care 18%2 Things to do in ward 13% Cleanliness7%3Information7% Relationships with staff 7%4Temperature6% Care from other clinicians 5%5 Ward facilities 6% Visiting arrangements 5%6Sleep Noise Levels 6%6% Relationships with patients 5%7Decor6% Thompson A (1986). The soft approach to quality of hospital care. Int J Quality and Reliability Management, 3(3), 57-65.

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

31. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 What can society do? Voluntary and community groups can train professionals in ways of communication in relation to specific conditions or population groups 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 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 Influence policy and planning to require patient-centred working practices

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

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

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

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

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

37. Andrew ThompsonWhat is patient satisfaction? VII Meeting of INGID, Budapest, Hungary.5 th October 2006 Concluding comments To decide on the value of patient judgements, there is a need to know: To decide on the value of patient judgements, there is a need to know: causes of satisfaction and dissatisfaction causes of satisfaction and dissatisfaction meanings and importance of health care 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 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 Need to embrace subjectivity and work to understand it to create patient-centred services and a coherent theory of patient satisfaction