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EDITORIALS: Angela Coulter Can patients assess the quality of health care? BMJ 2006; 333: 1-2 [Full text]

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Yes They Can And They Should

Dr. Herbert H. Nehrlich   (3 July 2006)

Patient assessment of quality of care

George E. Pickett, 25301   (4 July 2006)

Assessors for quality of healthcare

MK V Sathyamoorthy   (4 July 2006)

Patients' role in workplace-based assessment of healthcare

Douglas J Murphy, Stewart W Mercer, David Bruce, and Kevin W Eva   (5 July 2006)

Patient involvement in health care will improve quality.

Robert Hunter, Rosie Cameron, National ICP Coordinator   (7 July 2006)

Letter to the Editor

Rebecca C. Jonnerhag   (2 September 2006)

Yes They Can And They Should 3 July 2006
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: Yes They Can And They Should	Patients are the recipients of what is euphemistically called "health care". Doctors used to write prescriptions in Latin for the simple reason of creating an intellectual gap . The patient was expected to blindly trust the doctor. Today, where there is no longer much left of an atmosphere of trust in most human to human transactions, it is a wise patient who becomes informed and who questions the doctor's every move. These patients are usually labelled obnoxious, they often come in with a list of questions and sometimes with clippings from newspapers. Not many physicians enjoy their company. Patient satisfaction, whatever that might entail, dictates who will get the business in the community. Bedside manner is important. The fact that bedside manner, looks, reputation and a nicely furnished surgery (with refreshments in the reception area?) have little to do with the quality of the "care" the patient receives is of little importance. Who should judge the quality of health care? Surely not the colleagues or Pharma reps. It's a bit like poetry. Most critics will tell you that there are certain rules and expectations in modern poetry, that rhyme is well and truly dead and that Rod McKuen was an absolute failure. However, the people who read poetry, the masses for whom the poems are written, are the judges. They prefer rhyme and they like McKuen. And so it should be. We have all seen and continue to observe what happens when "experts" decide what is good for the common man. Competing interests: None declared
Patient assessment of quality of care 4 July 2006
George E. Pickett, Retired Charleston, WV, USA, 25301 Send response to journal: Re: Patient assessment of quality of care	I agree that patient evaluations of the technical quality of care are unreliable. However, patient interviews re the care process are very enlightening, especially for chronic problems. Their responses about the use of counseling re smoking, or the use of evidence based medications in the treatment of hypertension, CHF, diabetes and many other diseases are often of more value that medical chart review. Physicians often to not record their suggestions and patients often do not comply -- a problem better attributed to physician inadequacies than the patient's. Competing interests: None declared
Assessors for quality of healthcare 4 July 2006
MK V Sathyamoorthy, SHO Anaesthetics B71 4HJ Send response to journal: Re: Assessors for quality of healthcare	Patients as the consumers do play a significant part in assessing the quality of the healthcare that they receive. But again when we assess the quality we need to compare with certain set standards. But as many of our patients have not been exposed to the multitude of health care services it is therefore likely that some of their prejudices can become incorporated into their assessments. What we need is a fair and robust assessment tool which can be applied universally by all the consumers. There is still much work that needs to be done in developing this assessment tool. Just measuring the amount of chocolates received in a ward or the number of Thank you cards received or the number of complaints received etc is simply not enough and robust. Having said that, all patients are not experts and they will not be in a position to assess all the components of their health care delivery. Peer review process will also aid in the quality assessment and there has been some developments in this area. Quality of care depends on a multitude of factors and not just bedside manners, refreshments, posh buildings etc., Quality of care encompass the quality of surgery, complications during hospital stay, speed of decision making process including the reports on investigations etc., Competing interests: None declared
Patients' role in workplace-based assessment of healthcare 5 July 2006
Douglas J Murphy, GP Principal and Associate Adviser General Practice NHS Education for Scotland, 2 Central Quay, 89 Hydepark St, Glasgow, UK, G3 8BW, Stewart W Mercer, David Bruce, and Kevin W Eva Send response to journal: Re: Patients' role in workplace-based assessment of healthcare	Dear Editor, In your editorial, in the BMJ of first July, you asked a general question, “Can patients really make reliable judgements on the quality of health care?” It is our view that patients’ opinion can play an important part in the assessment of individuals’ workplace-based performance to deliver quality health care. Rao and colleagues highlight potential problems by the demonstration of weak correlations of clinical quality outcome markers with patient survey scores for technical quality(1). This is an interesting and important finding but as you point out patient satisfaction questionnaires are unlikely to be perceived by stakeholders to offer a sole measure of clinical practice. We are currently involved in a pilot involving nine deaneries and 171 GP registrars to develop workplace-based performance tests (the does do) to add to proposed competence assessments (the can do) for the development of new MRCGP (nMRCGP) for independent licensure for UK general practice. We are evaluating six assessment tools including patient satisfaction: video; multi-source feedback (MSF); significant event analysis (SEA); criterion audit; referral letters; and Communication and Relationship and Empathy (CARE)(2,3) patient questionnaire. We have evaluated stakeholder perceptions (educationalists, GP trainers and registrars) of these assessment tools to test the qualities of General Medical Council (GMC), Good Medical Practice(4). CARE is expected to test the domain of Relationships with Patients but not Good Clinical Care. A key point is that there is no “golden bullet” in assessment. An individual‘s performance on any one problem is context specific(5). It is non-predictive of that individual’s performance on other problems. Just as one would never trust a single multiple-choice question to provide an accurate indicator of knowledge, performance indicators should be sampled with sufficient breadth of content and context. Appropriate testing will require a range of methods(6)to inform the measure or monitoring of doctors’ performance for it to be fair and trustworthy. There is a need for multiple tools and context of assessment if outcomes for individuals are to be valid and reliable and adequately sample workplace-based performance. Every practitioner has areas of strength and other aspects of need in their workplace performance. In the future it will be important to provide feasible, valid and reliable feedback to individuals on an adequate sample of their performance. Even then it will be necessary to make available a mentoring service to support physician feedback. Skilled trainer or appraiser support to promote reflection, learning and change, can increase acceptance(7) as we strive to find robust methods to reassure both the public and the profession that responsibilities are being met and progress made. We will complete the analysis of the reliability of the piloted tools including CARE in time to report to the UK Post Graduate Medical Education Training Board (PMETB) this autumn. Yours faithfully, Douglas J Murphy, Stewart W Mercer, David Bruce and Kevin W Eva Competing interests: None References 1. Rao M, Clarke A, Sanderson C and Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ 2006; 333:19-22 2. Mercer SW, Watt, GCM, Maxwell M, and Heaney DH. The development and preliminary validation of the Consultation and Relational Empathy (CARE) Measure: an empathy-based consultation process measure. Family Practice 2004, 21 (6), 699-705 3. Mercer SW, McConnachie A, Maxwell M, Heaney DH, and Watt GCM. Relevance and performance of the Consultation and Relational Empathy (CARE) Measure in general practice. Family Practice 2005, 22 (3), 328-334 4. General Medical Council. Maintaining Good Medical Practice, General Medical Council, London, 1998. 5. Eva KW. On the generality of specificity. Medical Education 2003; 37: 587-588. 6. Schuwirth LWT, van der Vleuten C. Changing education, changing assessment, changing research. Medical Education 2004; 38: 805-812. 7. Sargeant, Mann & Ferrier, Medical Education 2005:39: 497-504. Making available a mentoring service to support physician feedback, reflection, learning and change, can increase acceptance and use of feedback. Competing interests: None declared
Patient involvement in health care will improve quality. 7 July 2006
Robert Hunter, Professor, R&D Director Gartnavel Royal Hospital, Glasgow, G12 0XH, Rosie Cameron, National ICP Coordinator Send response to journal: Re: Patient involvement in health care will improve quality.	Dear Editor Coulter suggests that patients should be asked to provide detailed reports of ‘their experiences of clinical care during a particular consultation’ and that they should be asked about what ‘actually occurred’ rather than seeking the patient’s evaluation of what occurred. We agree with her suggestion that it is a generalisation too far by Rao et al (1) to state that patients are unable to assess the quality of care they receive. We would go further to suggest that perhaps a more useful approach is the idea of building working partnerships for care, also referred to by Coulter, when she stated that most patents prefer doctors who involve them in treatment decisions and closely allied to this, doctors who respect patients’ dignity(2). There is much scope for incorporating into routine healthcare, patients’ views on their health needs and their own assessment of progress towards treatment goals, particularly in the case of chronic diseases. In Coulter's example of BP measurement, perhaps encouraging patients to become active participants who take responsibility for working towards their treatment goal (e.g. by ensuring their BP is regularly checked) could contribute towards improving quality. In this way partnership between patients and doctors drives the quality agenda. We have recently followed up a cohort of 1000 patients with schizophrenia using an approach where patients’ views were assessed in a structured format. Although treatment alliances are often thought to be more problematic in mental health, we found that patients could contribute accurate information to their care plans on needs and accurately comment on clinical outcomes(3). Furthermore, by utilising patient centred assessment tools, effective alliances developed between clinicians and patients that were associated with reduced hospitalisation and other improved pragmatic outcomes. We would suggest that such approaches are much more likely to improve clinical quality rather than relying on patient assessed measures of quality via rating-style questionnaires. 1. Rao M, Clarke A, Sanderson C and Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ 2006; 333:19-22 2. GfK NOP Social Research. Annual tracking survey. London: General Medical Council, 2006. 3. Hunter R, Cameron R. Scottish Schizophrenia Outcomes Study 2006. NHS Quality Improvement Scotland. http://www.healthquality.org Competing interests: None declared
Letter to the Editor 2 September 2006
Rebecca C. Jonnerhag, Postgraduate student, Master of Health Services Management Monash University, Melbourne, Australia Send response to journal: Re: Letter to the Editor	Dear Editor There are documented limitations to the use of patient satisfaction surveys spanning from patient characteristics to process and structure of the care provided [1 and 2] and I agree that patient satisfaction surveys must be used advisedly as a supplemental tool for quality improvements in healthcare. Surveys and questionnaires can be a useful tool for quality improvement however the reliability and usefulness, depends on several critical factors during the gathering and processing of the data and delivery of the results. Coulter implies that the usefulness of this tool will be improved if the results are published, making them accessible for both peers and patients. [1] The reason for increased disclosure of such results is that patients and other stakeholders can make more informed choices. The downside to disclosure is that there may be incentive to manipulate results by the presenter for their own benefit. In addition to data manipulation is the lack of its use to implement quality improvement. Several countries in Europe have made patient satisfaction surveys mandatory. However studies have shown that while these surveys are useful in healthcare quality initiatives, little has been done with the data to deliver intended improvements. [3 and 4] The final aspect in healthcare quality assessment is that the patient’s perception of an outcome may not necessarily be fairly assessed in a survey. A patient satisfaction survey usually takes a snap shot of a particular point of time during the process rather than assessing it as a whole and thus only giving a limited perspective on the quality of care given. Donabedian, a healthcare quality guru, has defined a framework through which quality can be examined and assessed; structure, process and outcome. [5] We must utilise surveys that follow this framework through the continuum of patient care. It is my opinion that patient satisfaction surveys can be of benefit but they must be carefully constructed, assessed and processed to ensure quality and accurate data is the outcome. Following that, these outcomes must be used to drive the processes of improving quality in a rational manner that facilitates improvement rather than causing defensive reactions. This will increase their utilisation and create a culture of healthcare quality improvement. References: 1. Coulter A. Can patients assess the quality of health care? BMJ 2006; 333: 1-2. (1 July.) 2. Cleary PD, McNeil BJ. Patient Satisfaction as an indicator of quality care. Inquiry 1988; 25:25-36 3. Scott A, Smith RD. Keeping the Customer Satisfied: Issues in the Interpretation and Use of Patient Satisfaction Surveys, Int J Qual Health Care, 1994 6:353-359 4. Boyer et al. Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital. Int J Qual Health Care 2006, Aug 24 5. Donabedian, Explorations in Quality Assessment and Monitoring, vol. I: The Definition of Quality and Approaches to its Assessment (Ann Arbour, MI: Health Administration Press, 1980) Competing interests: None declared