Can patients assess the quality of health care?
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7557.1 (Published 29 June 2006) Cite this as: BMJ 2006;333:1All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests