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Target surveys to areas needing improvement
Suppose your agency’s patient satisfaction survey results indicate that most patients rate the agency’s quality of care as "excellent." Does this mean the quality manager can pack a bag and say the job’s been done? Or does it mean the survey didn’t ask the right questions? And how does one agency’s "excellent" score compare with another agency’s "excellent" score?
Those are the questions that can make quality managers’ work a little tricky when they’re trying to analyze satisfaction survey results.
So why bother with surveys at all? The answer: Quality managers will find the results of a patient satisfaction survey to be very useful, if they have made sure the survey is valid, reliable, and highlights areas the agency can target for quality improvement.
Home care agencies have a greater challenge than other types of organizations when it comes to interpreting client satisfaction surveys because the home care industry typically is rated high by its clients, says Jan Brien, MS, director of Parkside Associates in Park Ridge, IL. Parkside Associates, which specializes in patient, physician, and employee surveys that guide and evaluate quality improvement programs, has provided surveys and research services to more than 600 health care providers nationwide.
Parkside recently conducted a 183-agency patient satisfaction survey of 16,727 home care patients. Overall, 64% of the respondents said their home care experiences and quality of care were "excellent." Another 25% said their services were "very good;" About 9% said the services were "good," and only 2% called their home care services "poor" or "fair."
"Overall, we found that in general this industry is a very positive industry," Brien says.
However, the survey did highlight some areas that needed improvement. For instance, the survey found that patients expressed more satisfaction with the areas of care process than they did with the education process. Patients largely were satisfied with the amount of time a home care employee spent with them and whether the staff made them feel at ease or showed concern for them.
"We found that 98% of patients felt the home care staff were concerned about them as people," Brien says.
However, patients were a little less satisfied with how the staff involved them in the care- decision and goal-making process. They also expressed less satisfaction with how home care staff encouraged questions and explained medications and procedures.
"It’s important to note that the care process and patient involvement are the two areas that have the most impact on how patients rate overall quality of their encounter," Brien says.
A home care agency that finds these types of discrepancies in a patient satisfaction survey could easily target patient education in a quality improvement project. But before a quality manager makes use of such information, the agency must have a reliable and valid survey.
"Not every survey will be effective for measuring quality improvement," Brien says. "You need to make sure you’re working with a good questionnaire to begin with." This is not as easy as it sounds. She suggests quality managers these guidelines:
• Make sure there’s evidence for reliability and validity in the survey.
Reliability and validity are related to what kind of scales are included on the survey. The survey questions should be able to cluster to form scales, and the scales should be reliable, Brien says.
"That means the items within the scales should have strong evidence of internal consistency, which is the appropriate statistical term for multi-item scales," she adds.
There have to be at least two items to make a scale. Often the more items that are included on a scale, the stronger the reliability. However, there are exceptions. One of the scales on Parkside Associates’ home care survey has only two items, yet it is very reliable, Brien notes.
Parkside Associates’ home care survey has four scales — the care process, patient involvement and education, orientation to home care, and perceived medical outcome.
While reliability pertains to how internally consistent the scale items are, validity is how well each of these scales predict overall quality of care since improving quality is the survey’s goal.
Home care agencies could use a survey that already has validity and reliability built into it, or they could create their own survey if they have access to someone with statistical knowledge, Brien suggests. "I have seen some independent surveys that are pretty good in terms of the way they are constructed."
• Create an effective sampling method.
The sampling method should be determined by an agency’s plan for analyzing data. For example, if a multisite agency wants to look at client satisfaction in various sites, then the agency should stratify its sample by site.
Parkside Associates had the home care agencies in its study send out 300 customer satisfaction surveys. Their average rate of return was 53%.
The quality manager should look at the data and make sure the sample size is adequate for an analysis. Sample size adequacy is determined by the estimated number of errors. The larger the sampling size, the smaller the chance of error affecting the results. Brien says that a mailing of 300 surveys with a 53% response rate is large enough to yield a low level of error.
Quality managers can follow several strategies to make sure they have a high enough response rate, which typically would be in the 40% to 50% range. Assuming an agency mails its surveys, which is much less expensive than telephone surveys, here are some ways to increase the response rate:
Brien recommends they send a survey to a patient only once in a six-month period. "It might be difficult for home health agencies to track that, to pull the samples, but that really can affect the response rate," she adds.
• Don’t overanalyze the survey results.
"When creating a report on the survey, only do the analysis you need," Brien says. "Sometimes people overanalyze the results when they should just get the key information, no more and no less, and it should be understandable, because understandable equals usable."
To integrate patient satisfaction results into a quality improvement or continuous quality improvement process, Brien suggests quality managers do the following:
"It’s important to keep careful watch over the outcome of care that’s provided to your patients because one outcome is their perception of the care," Brien says. "And if you’re doing continuous quality improvement initiatives, then you want to measure the impact of your initiatives."
• Follow basic QI principles to turn survey results into project.
Brien says one home care agency cannot "photocopy" another agency’s success story because quality improvement doesn’t always work the same for different organizations. However, if a quality manager identifies a potential problem area based on customer satisfaction surveys, there are some basic steps the agency could take to solve the problem.
For example, Brien says, suppose patients expressed some dissatisfaction with the timeliness of visits. The first thing a quality manager might do is gain a better understanding of how late employees arrive at patients’ homes.
"You want to collect baseline data, collecting information on the number of minutes past arrival time, and then do a flowchart of the process," she says.
Next, the quality manager will develop intervention strategies, which for one agency might mean a new scheduling system. Another agency might hire additional staff. A third agency might give staff better maps and directions to clients’ homes.
After the agency makes changes, the quality manager again should measure the amount of time past scheduled appointment that employees arrive at patients’ homes. If there has been some improvement, then the quality manager will look for an improvement in the customer satisfaction scores on that particular indicator.
• Jan Brien, MS, Director, Parkside Associates, 205 W. Touhy Ave., Suite 204, Park Ridge, IL 60068. Telephone: (847) 698-9866.