Abstract
Following your last hospital visit, you may have been asked to fill out a questionnaire about your satisfaction. Patient satisfaction surveys have become a familiar fixture in health care delivery, providing an avenue for patients to shape the delivery of care. 1 They tend to be low cost and easy to implement – likely to be a reason for their widespread use 2 – and the rationale behind them is sound and simple: providers can adjust how they deliver care based on the post hoc feedback they receive.
Patient satisfaction surveys can serve other purposes as well. For example, satisfaction scores have been incorporated into pay-for-performance agreements. 3 They have also been used for benchmarking and quality improvement. 4 The patient satisfaction metric has been revered as a gold standard for quality improvement and accountability, 5 and providers rely on it heavily as a way to see care ‘through the eyes of the patient’. Upon closer examination, patient satisfaction data have some important limitations, so collecting and analyzing them should be viewed as one aspect of a broad strategy for involving patients in the design and improvement of health care.
How valid are patient satisfaction data?
Since they have many applications, it makes good sense to ensure patient satisfaction data are valid. A standard definition, however, remains elusive. 6 Do we truly understand what it means when a patient expresses a high (or low) degree of satisfaction with care? What if satisfaction with care was determined by variables outside of providers’ control? Indeed, research on conventional satisfaction surveys shows that aspects of care delivery – for example, a patient’s length of stay – play a role in satisfaction, but parameters independent of care delivery – for example, a patient’s age – may play an even greater role. 7,8 Even in organizations that provided less than ideal care, a lack of information and a reluctance to be negative led to patients’ expressing artificially high levels of satisfaction. 9
These findings make measurement of satisfaction particularly challenging, which explains the growing attention toward this area of research. Recent studies show that expectations for care are a significant predictor of satisfaction. 10,11 If patients perceive their providers as being under pressure or constrained, aspects of care which they would otherwise expect may be overlooked without penalty. 12 If we extend this logic to the Canadian context, perhaps high levels of satisfaction can be explained in part by the widespread belief that its health care system is in a state of crisis. 13
Enhancing patient involvement
So if satisfaction data suffer from these limitations, are they still worth collecting? The answer is a qualified yes. As mentioned, work has been done to develop better, validated satisfaction surveys. And surveys are beginning to capture more information about patient experience, not just satisfaction. Indeed, health care providers are beginning to recognize that understanding patient experiences is vital to designing and delivering high-quality health services. 14 NRC Picker Canada highlights the advantages of moving from questions on satisfaction (e.g. ‘how satisfied were you with the information provided at discharge?’) to questions on experience (e.g. ‘did hospital staff tell you when you could resume usual activities after treatment?’). Patient responses to questions on experience can help organizations understand their performance on controllable behaviours that drive patient experience, and are vital for developing plans to improve patients’ experiences.
That said, meaningful patient engagement goes beyond asking discrete questions and tabulating the answers. The collection of satisfaction and experience data is but one component of a broader patient engagement strategy. To overcome some of the limitations of these surveys, providers may begin asking more open-ended questions or holding focus groups with patients.
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Providers may also decide to form patient/family advisory councils, participatory models that are reflective of genuine patient involvement.
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Patients can also be intimately involved in efforts to (re)design care.
16,17
Bate and Robert
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suggest a continuum of patient involvement (Figure 1), from ‘complaining’ and ‘information giving’, to ‘experience-based co-design’.
Continuum if patient involvement.
Conclusion
Knowing whether patients are satisfied with the care they receive can be useful for improving the quality of health services. Even more important is measuring patient satisfaction in ways that are validated and reliable. 12,19 That said, even a score of high satisfaction on a validated questionnaire does not necessarily imply high-quality care has been provided. To be successful in improving health services to meet patients’ needs and preferences, providers must have comprehensive patient engagement strategies that include the patient and/or their family members as full partners in the enterprise. 20
Disclaimer
Mythbusters articles are published only after review by experts on the topic. CFHI is an independent, not-for-profit corporation funded through an agreement with the Government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CFHI. Production of this Mythbuster has been made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer.