The Quality-Cost Connection: Taking measure with focus groups

Feedback technique can foster frank discussion

By Patrice L. Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Health care organizations everywhere are using focus groups of consumers to critique services, rate educational materials, offer feedback on patient safety, or register kudos and gripes about the quality of patient care.

The major appeal of the focus group process is its versatility. Focus groups can provide a convenient forum for frank discussion and stakeholder feedback on different aspects of health care services at various stages, from new ideas to long-standing programs. The ideas and options of focus group participants can be valuable to leaders conducting formative evaluations to improve services as they are implemented or to make existing services even better. Another appeal of the focus group technique is that customers enjoy being asked to share their opinions in a short meeting with other people who have similar interests, passions, or experiences.

Yet despite the buzz about focus groups, the information gained is not always worth the effort. Without adequate pre-planning and precise execution, gathering data from stakeholders through focus groups can be a waste of time. There are several essential ingredients in the focus group process that affect whether the activity yields solid qualitative data:

A topic that matters

The discussion topic for the focus group should have immediacy and be of interest to every member. The topic of the focus group session should be stated clearly in the invitation to participants. Indicate the group’s purpose, what your organization hopes to learn, and what you aren’t able to do in the session. For example, if you need to hear what caregivers can do to help patients feel safe during their health care experience, make those parameters clear at the beginning. Participants’ job in a focus group is not to solve problems or to create a new system or plan. Their job is to focus on the topic, give their unedited ideas, respond to others’ points, explain their preferences, and share their experiences.

The right people

Selecting the right participants for a focus group can be tricky. Random sampling is unnecessary and probably won’t produce the right mix of people. Purposeful sampling usually works well. First, develop a pool of potential participants. Include people who have something to say. Group those with a common connection to the topic. You might want to hear several different perspectives, but you need different focus groups for that result. Individuals’ connection to the topic is the common bond that helps create a comfort level that propels the conversation.

A focus group on patient safety could include former patients or their family members, as well as potential future customers. You may wish to host one patient safety focus group for patients with chronic conditions at higher risk of hospitalization and another group for patients who only interact with the hospital episodically (e.g., for maternity care, short-stay elective surgeries, etc.). Sometimes the common bond is something all focus group participants have NOT done, i.e., none of them have been hospitalized in the past year, but they have an opinion on the safety of hospital services.

Six to 10 people is about the right size for a focus group, which means you’ll need to invite 12 to 14 people. Most likely, some people won’t participate or will have a last-minute conflict. Fewer than six participants will not produce enough discussion. Too many people can result in side conversations that distract from the discussions. Ideally, the focus group participants do not know each other well or at all.

A trusting atmosphere

A trusting atmosphere is critical to capturing good focus group data. Provide a comfortable setting in a convenient location. It may be less threatening to hold focus groups at community centers or churches, rather than within the hospital building. Create a welcoming atmosphere with easy-to-read signs directing participants to the location and a registration table. A staff member or volunteer should greet each person. Provide nametags or table tents to encourage participants to address each other during the discussion.

Refreshments are not essential but help break the ice and make people comfortable. Make them available 30 minutes before the session. Depending on the topic, some participants may bring their children. Anticipate this potential and have supervised child care available. This can be a separate play area or a children’s movie offered in an adjoining room.

A skilled facilitator

Facilitating a focus group requires skill and an appreciation for the process. The facilitator should not be closely involved with the issue being discussed. For example, if the group’s discussion will focus on patient safety, use a facilitator who will be viewed as being neutral (for instance, someone from a nonclinical department or a member of the clergy).

The success of group discussions is strongly linked to the facilitator’s skill in asking questions, tracking the flow of conversation, and soliciting feedback from everyone. The facilitator must be able to model good listening skills and make it possible for participants to respond to one another, not just answer direct questions. Different points of view must be encouraged. Don’t use untrained facilitators who lack the skills to probe for clarification, get examples from participants and encourage participants to respond to each other. If most interactions are between the facilitator and one participant, the value of group dialogue is lost.

Some good questions

Different kinds of pre-planned questions should be used during the focus group discussions. Open the session with questions intended to get everyone to speak without discussing the topic in any depth. Then move on to key questions about one-third of the way through the meeting. Questions that might be asked during a focus group on patient safety include:

1. Did your nurse spend a sufficient amount of time explaining tests or procedures?
2. Did you feel appropriately involved in your care?
3. Were you encouraged to ask questions?
4. Were there any unplanned events in your care? If so, were you kept informed in a timely and satisfactory manner?

Responses to each key question should take 15 to 20 minutes, depending on how people answer. A well-trained facilitator will clarify responses when necessary, encourage feedback and new ideas, and know when to move on. At times it may be appropriate for participants to write their answers, rather than respond verbally. For example, participants might rank how safe they felt during their last hospitalization from 1 to 10 on an index card.

Closing the discussion session involves more than thanking everyone and bidding him or her farewell. The facilitator should offer some "final thoughts" comments that synthesize the discussion. During closure, the facilitator can ask questions such as, "If we were to change the patient care process to help you feel safer during your next hospital stay, what is the one change that you consider most crucial?"

A system for recording discussions

There are many ways of recording focus group discussions: note taking or audio or video recording. Interpretation of the results relies on the quality of the record of the session. So it is important to make adequate provisions for recording the discussions.

To obtain a complete and accurate record of discussions, plan to audio- or videotape the session. These recordings provide a record of the whole session for anyone who was not present but would like a detailed knowledge of the results of the focus group. Recording also can be helpful for note-taking observers to clarify issues that may be unclear after the fact. Always ask permission of the participants to record the session.

Some organizations rely solely on note taking to record the focus group discussions; however this does have some limitations. Don’t expect the facilitator to keep notes. Another individual should be designated as the observer and be responsible for recording the discussions. Often, it is nearly impossible to fully document each participant’s response verbatim. Pen-and-paper note taking usually can capture only summaries of each response. However, the observer should try to record direct quotes when interesting or informative statements are made.

If the session also is being recorded electronically and will be transcribed later, note taking can be limited to jotting down a few words that are used later to remind people of what was said and when. If the electronic recording is merely a record that will be used only if necessary, then written notes should be as complete as possible. After the session, it may be helpful for the observer and facilitator to add remarks about any nonverbal messages that were exhibited during the discussions.

A plan for data analysis

Analyzing the results of focus group discussions involves examining the data from various perspectives to determine the major and minor themes and subpatterns. If your organization has sponsored more than one focus group on the same topic, the evaluation process also should include a cross-group analysis.

The people who analyze the data should have observed the discussions, either by being physically present with the group or by reviewing an electronic recording. Often, nonverbal messages cannot be expressed adequately in a written transcript.

Focus group sessions are an excellent way for health care organizations to discover the attitudes of external and internal customers relative to a wide variety of different topics. The interaction between organizational representatives and customers is one of the most important parts of the process. With careful planning and precise execution, health care organizations can maximize the learning possibilities of focus groups.