Accurate assessment of clinical nurses' work environments: Response rate needed

Improvement of hospital unit work environments is key to quality patient care, productivity, nurse retention, and job satisfaction. Accurate measurement of such environments is necessary prior to introduction and evaluation of improvement structures and strategies. Characteristics and attributes of work environments are group level phenomena. Accurate assessment of these phenomena requires survey response rates of sufficient size to ensure sample representativeness and data that can reliably be aggregated to group level. What is the sufficient response rate? This question was answered through psychometric testing of five random samples from the population of 23 M.D. Anderson Cancer Center clinical units that had 100% response rates on an environmental survey. Response rates of 40% or more had acceptable psychometric properties for unit‐specific scales. © 2009 Wiley Periodicals, Inc. Res Nurs Health 32:229–240, 2009     

Using satisfaction to measure the quality of palliative care: a review of the literature

BACKGROUND: The advent of clinical governance in British health policy has placed increased demands on health care providers and practitioners to ascertain the quality of their services. Traditional indicators of quality of health care, such as death or recovery rates, are not appropriate in palliative care. Thus, it is important to establish alternative approaches to measuring the quality of palliative care services and interventions. AIMS: Satisfaction levels have been used widely in palliative care to assess quality. A literature review was conducted which aimed to explore the strengths and weaknesses of using satisfaction as an indicator of the quality of palliative care services. It also aimed to provide a solid basis upon which further work could be built. METHODS: Five electronic databases were searched using key words and phrases and key authors. Hand searches were conducted of four journals that contributed significantly to the concept of satisfaction, and reference lists of reviewed papers were scrutinized. Relevant papers were reviewed, data were extracted and these data were thematically analysed. FINDINGS: There are a number of important unresolved issues in the literature with regard to using satisfaction as an indicator of the quality of palliative care services. First, few alternatives to satisfaction are available. Secondly, satisfaction is under-theorized and no widely accepted definition exists. Thirdly, there are methodological inconsistencies across studies. It is important to take into account these findings when planning and implementing change following service evaluation using satisfaction as a measure. CONCLUSIONS: Relying on findings of satisfaction surveys to determine clinical and policy amendments in palliative care may not result in improvements in overall quality of care. Using satisfaction as a method of assessing the quality of health care services is particularly problematic and requires further investigation in both practical and conceptual terms.     

Measuring patient satisfaction for quality improvement

BACKGROUND: Surveys used for health plan quality reporting are generally administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. Therefore, surveys may lack sensitivity to measure the effects of patient-focused, quality improvement initiatives that could demonstrate results in a shorter time period. OBJECTIVES: We describe the development and testing of a multidimensional, visit-specific measure of satisfaction with primary care that may be used in quality improvement. METHODS: Conducted in five adult and pediatric primary care sites serving a commercial, largely managed-care population, the survey includes the Medical Outcomes Study Visit-Specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. We assessed the instrument's reliability, validity, and utility for quality improvement. RESULTS: For both adult and pediatric samples, three factors emerged: satisfaction with the provider, satisfaction with access, and satisfaction with the office. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both samples; satisfaction with access was significantly correlated with overall satisfaction only for adults. For adults, patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the health plan. Finally, for adults, we detected significant differences across practice sites in terms of satisfaction with office and access; for children, there were intersite differences in terms of satisfaction with provider, office, and access. CONCLUSIONS: We have support for the reliability and validity of this instrument that has identified differences in satisfaction between practice sites that may be used for quality improvement.     

Clients' perceptions of opioid substitution treatment: an input to improving the quality of treatment

Despite the emphasis on providing high quality mental health and addiction treatment, there has been relatively little consideration given to examining clients' perceptions of addiction treatment (consumer satisfaction) as a quality improvement strategy. The present article reports on a survey of a representative sample of 93 clients receiving opioid substitution treatment (OST). Employed participants reported higher treatment satisfaction and a pattern of positive associations was found between satisfaction and general health, mental health, social functioning, lower methadone doses, and participants' ratings of their treatment progress. Lower satisfaction was associated with higher frequency of benzodiazepine use, and, for women, longer treatment duration. Māori participants rated their treatment progress as lower than that of non-Māori. Results strongly endorse recording participants' comments to provide a deeper understanding of survey item ratings. The study findings highlight the need for a research focus on the roles of mental health and other registered nurses who work with people receiving OST in specialist service and primary care settings, and endorse a partnership approach to future research in this area. The pattern of findings arising from this study suggests key strategies for improving the flexibility and client responsiveness of OST.     

Using customer input to improve managed care performance

How do you get the information you need to manage your company's health care plans effectively? Consider a "customer satisfaction survey" that gathers data from the people who use the plans every day: employees. Make the data work for you when you negotiate costs, communicate key plan features, and look for ways to improve health care quality and upgrade the service you and your employees get from your health plans. American Express and the Chicago Health Plan Value Project (a unique group of 14 companies and 7 health plans) tried this approach, and they now expect a "win-win-win" situation all around.     

Continuous quality improvement in the ambulatory endoscopy center

What does quality assessment have to do with the practicing gastroenterologist? Why should one spend the time and effort to incorporate CQI activities into an already busy practice? First and foremost, quality improvement should directly benefit the patient by ensuring that they receive the highest quality of care possible. For example, comparing endoscopic use or outcomes, such as procedure success or complications, with national standards or other endoscopists in the same community may identify physicians who could benefit from additional training. Similar analyses may likewise identify outstanding physicians who might serve as resources for other physicians. Surveys of patient satisfaction may reveal deficiencies, which might be unknown to a physician who is otherwise technically excellent; deficiencies that would never have been uncovered by traditional measures of quality. Second, applying the techniques of CQI to study one's own practice can provide a competitive edge when vying for managed care or corporate contracts. In this regard, CQI can be used to document physician or practice performance through tracking of endoscopic use, procedure success and complication rates, and patient satisfaction. Finally, the rising concern among various patient advocacy groups has led to an increased emphasis on quality improvement, and in most cases it is a required activity as part of the accreditation process. Steps to quality improvement There is more to quality improvement than simply selecting and implementing a performance improvement plan. A number of steps have been suggested to achieve fundamental improvement in the quality of medical care [3]. The first is to use outcomes management for improvement rather than for judgment. One of the major criticisms of QA is that it will be used to judge physicians providing care. It is feared that CQI will be used to identify poor performers who will then be punished. This strategy leads to fear and inhibits an honest pursuit of improvement. Second, learning must be viewed as a process. A quality improvement plan that is successful in one setting may not be as favorable in another situation. Clinicians must be able to focus on their individual situations and adapt what others have implemented to their own practice. Third, the most important aspect of the quality improvement is the implementation step. It matters little if elegant studies of endoscopic complications or patient satisfaction are completed if the information is not used to improve the delivery of health care to every single patient. The delivery of medical care continues to evolve. Resources are becoming increasingly scarce and the progressive rise of health care expenditures suggests a need for control. In this zeal for cost constraint, quality must not be sacrificed. This new-found attention to quality must be extended to the level of the individual practitioner to ensure that individual patients' interests are protected and the best possible care is delivered regardless of the economic implications. As providers of health care, endoscopists need to take an active role in these efforts both in understanding and implementing the techniques of quality assessment into their practices. If physicians are not actively involved in data collection and measurement to improve the quality and value of their own work, someone else will undoubtedly assume this role.     

Implementing CQI: measuring levels of service quality at physiotherapy clinics

The purpose of this study was to provide a profile of patient perceptions of the service quality delivered by a back pain rehabilitation clinic. Data were gathered and analyzed at the clinic level in twelve different locations across Canada. Measurement techniques were based on validated survey methods and developed from a growing stream of social science research. Results provided clinic managers with a profile of perceived service quality in terms of three key aspects: administrative support, quality of therapy received, and satisfaction with the results. The results also provided each clinic with benchmarks so that on-going service quality measurements can be incorporated into a system of continuous quality improvement. This process can assist rehabilitation clinics (and other health care providers) in improving service as well as ultimately reducing the costs of providing treatments involving physiotherapy.     

Team and patient orientation in nursing as a part of quality management--status and needs for research

The paper introduces a holistic concept of quality management in hospitals--the approach of employee and patient orientation ("MPO-Mitarbeiter- und Patientenorientierung"). It is shown that quality in health care does not primarily depend on the regulation of quantitative input and output of the health care system but is largely determined by improvements of processes within the system. TQM models like the European Quality Award are showing the way towards improving processes by focusing on employee and client orientation and satisfaction. Patient satisfaction has become a more and more popular indicator for quality in health care. However, reviews of the vast amount of literature on patient satisfaction reveal that present research suffers from the same problems and shortcomings that have already been criticised about 20 years ago. Only few studies choose innovative approaches by integrating the perspectives of patients and employees and by refraining from the insufficient measurement of satisfaction. Three of these studies are presented and compared. Against this background the MPO-approach is described; the approach integrates results from work psychology as well as from nursing research within the concept of complete activity. In contrast to other models of quality management the MPO-approach provides suitable methods for analysis and assessment of employee and patient orientation. These methods are described and are finally discussed with respect to strategies of total quality management in hospitals.     

Client satisfaction with nursing services. Evaluation in an occupational health setting.

Client satisfaction surveys have served as a valued appraisal tool of quality nursing care in various health care settings, but there is a paucity of published research using these tools in the occupational health setting. Employing a modified version of the SERVQUAL questionnaire, this study identified employees' current levels of satisfaction and perceived importance of nursing care provided by an occupational health program. Two hundred randomly selected employees were asked to participate by completing the survey, with 86 (43%) responding. Results indicated a positive correlation between client satisfaction and perceived importance of nursing care. Moderately high levels of client satisfaction existed in the sample. The use of client satisfaction surveys based on the strength of client preferences could identify areas of health care that need improvement.     

Implementation of a change process to improve outcomes of patients admitted to epilepsy monitoring unit

A continuous quality improvement in health care, combined with measurement of patient and organizational outcomes, is an international trend that promises improvement in meeting the needs of health care consumers in a cost-effective manner. A clinical improvement workshop was conducted in our institution to study the practical methods that can be used by clinical teams to improve the quality and value of health care. This workshop enabled the Epilepsy Team to identify change strategies that potentially could accelerate clinical improvement efforts in the epilepsy monitoring unit (EMU). The Team was able to develop, plan, and test improvements and link these improvements to patient outcomes.     

Lay carers' satisfaction with community palliative care: results of a postal survey. South Tyneside MAAG Palliative Care Study Group

This paper reports the substantive findings of a study that examined the feasibility of using postal questionnaires to assess the satisfaction of lay caregivers with the care received in the community by those dying of cancer. The focus of the analysis was the quality of information provided by health professionals, health services used in the final year of the dying person's life and the lay carer's views about the quality of these services. The study was a retrospective survey of lay carers identified from death certificates over a 9-month period. Of the 355 people contacted, 156 completed the questionnaires, a 44% response rate. The results of the survey indicate that information provision was deemed unsatisfactory by a large proportion of respondents, and that dissatisfaction with care received from hospital, the district nursing service and the general practitioner was common. Levels of satisfaction with care were clearly related to a range of service factors. Our survey also highlighted clear differences in the perceived quality of specialist and generic services for those dying of cancer. A comparison of the findings from this postal study with those reported in earlier retrospective interview surveys of lay carers suggests that the use of the postal questionnaire is a valid and cost-effective approach for assessing quality of care. The data provide baseline information against which improvements in the quality of care can be measured.     

Facilitating communication with patients for improved migraine outcomes

Effective communication is integral to good medical care. Medical professional groups, regulatory agencies, educators, researchers, and patients recognize its importance. Quality of medical communication is directly related to patient satisfaction, improvement in medication adherence, treatment compliance, other outcomes, decreased risk of malpractice, and increase in health care providers’ levels of satisfaction. However, skill level and training remain problematic in this area. Fortunately, research has shown that medical communication skills can be successfully taught and acquired, and that improvement in communication skills improves outcomes. The American Migraine Communication Studies I and II evaluated the current state of health care provider-patient communication in headache care and tested a simple educational intervention. They found problematic issues but demonstrated that these areas could be improved. We review theoretical models of effective communication and discuss strategies for improving communication, including active listening, interviewing strategies, and methods for gathering information about headache-related impairment, mood, and quality of life.     

Telehealth Utilization to Improve the General Surgery Patient Care Experience

Patient satisfaction and quality of care are key components of the patient experience. A quality improvement project was conducted to evaluate whether the addition of a nurse practitioner-led telehealth visit reduced the number of unplanned contacts by postoperative patients within the general surgery department. Although the number of unplanned contacts did not decrease, survey data revealed patients were highly satisfied with the telehealth experience. This project provided insight into the common problem areas in postoperative patients. This information can be used to target preoperative teaching to improve the patient experience.     

Understanding patient satisfaction with family doctor care

Rationale, aims and objectives Patient satisfaction is receiving increased attention in the evaluation of health care quality. However, qualitative methods have seldom been used to study patient satisfaction. The purpose of this study was to explore how satisfaction is understood from the perspective of patients receiving care from family doctors. Method We used a qualitative approach consisting of in‐depth interviews with 36 patients attending clinics in Poland. Interviews were audiotaped and transcribed, and content analysis performed. Results There was no single definition of satisfaction among study participants; however, some core characteristics of satisfaction emerged. These characteristics were: (1) good doctor–patient interaction; (2) health improvement or resolution of health problems; (3) fulfilment of prior expectations; (4) availability of health care; (5) combination of multiple characteristics; and (6) absence of dissatisfaction. Conclusion Because patients have differing concepts of satisfaction with health care provided by family doctors, quality assessments should focus on components of satisfaction whereas questions about satisfaction itself should be avoided.     

Current assessments of quality and safety education in nursing

Concerns about the quality and safety of health care have changed practice expectations and created a mandate for change in the preparation of health care professionals. The Quality and Safety Education for Nurses project team conducted a survey to assess current levels of integration of quality and safety content in pre-licensure nursing curricula. Views of 195 nursing program leaders are presented, including information about satisfaction with faculty expertise and student competency development related to 6 domains that define quality and safety content: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. With competency definitions as the sole reference point, survey respondents indicated that quality and safety content was embedded in current curricula, and they were generally satisfied that students were developing the desired competencies. These data are contrasted with work reported elsewhere in this issue of Nursing Outlook and readers are invited to consider a variety of interpretations of the differences.     

Assessing Patient Satisfaction in a Radiation Therapy Department Using a Survey Tool

PurposeThe purpose of this study was to use a survey tool to measure the level of patient satisfaction with current health care delivery in the radiation therapy department, and provide insight into how the department can improve quality of care.MethodsAn anonymous patient satisfaction survey was distributed to radiation therapy patients near the end of their course of treatment. The survey was distributed over a 1-month timeframe to outpatients more than 18 years of age receiving a radical course of treatment.ResultsOne hundred forty-five surveys were distributed, and 80 surveys were returned for a response rate of 55%. Patients were satisfied with their experience in terms of environmental features such as the waiting rooms and treatment rooms, accessibility and convenience of treatment including wait times, and the interpersonal relationships and clinical competence of the care providers. Results showed a variation in the use of support services depending on the treatment site.ConclusionThe survey tool was useful in showing that overall, patients were satisfied with the care in the radiation therapy department at the Princess Margaret Cancer Centre. The survey was also useful for comparing patients' opinions between treatment site groups. The survey responses provided few ideas for improvement strategies. For future directions, the survey may be distributed at regular intervals as a method of measuring levels of patient satisfaction on an ongoing basis.     

Year in review 2011: Critical Care - Resource Management

Increasing complexity and costs are a fundamental problem in critical care medicine, leading researchers to study opportunities and threats to continue to provide high-quality care in a more efficient health system. Over the past decades, we have learned from industrial methods that quality improvement and resource management can help achieve these results. Last year, Critical Care published a number of papers that highlight key points of critical care resource management. Each of these is grouped into one of three broad categories, based on domains of quality: (a) outcomes, in which we review long-term outcome data with an emphasis on the aging population, strategies to help mitigate the psychological burden of critical care, adverse events, and the appropriate use of resources, such as prolonged mechanical ventilation and intensive care unit (ICU) beds; (b) processes of care, in which we review variability in the provision of critical care, owing to gender, insurance status, and delays in ICU admission; knowledge translation studies in critical care; goal-directed therapy for postoperative patients and decision-making in the ICU; and (c) structure, in which we review strategies to improve quality through changes in design and the structural limitations to provide care in resource-limited settings.     

Using outcomes research to validate the advanced practice nursing role administratively

The health care system has been forced to respond to the demand for changes in care provision. The changes have produced an opportunity for APNs to become a partner in care in the ICU. With the new opportunities APNs have been challenged to quantify the quality and fiscal effectiveness of their practices in the critical care arena. Administrators have a vested interest in the success of the organization, which includes the concepts of fiscal viability and quality care and patient and family satisfaction. There are data available to help formulate the rational argument for the inclusion of APNs in critical care. By using the data APNs can prove that their presence has a positive impact on the quality and financial outcomes of care. APNs can have a positive impact on the organization in all of the ways that are important to the administration. They can transform the current practice and improve the quality of the care. In presenting the outcome data of the APN role to administrators, APNs can be successful in gaining support for their role. APNs are vital components of the healthcare system and gaining recognition of the true value of the role is key to ensuring the ability of APNs to meet today's healthcare challenges for the improvement of patient care.