Patient feedback questionnaires − why bother?

Patient experience, patient satisfaction and patient reported outcome measures

Historically, the terms patient satisfaction and patient experience have been used inter-changeably; however, they do not mean the same thing as the focus has shifted from the concept of exploring patient satisfaction to patient experience.

Based on recent literature, it is suggested that patient experience is concerned with all types of interaction that patients have with the healthcare system. It represents a range of patient health-setting/environment experiences, overall lived experiences, care experiences, clinical interactions, organizational features of care, and process measures.⁶ Questions regarding patient experience reflect specific and actual experience, such as ‘Were you able to get an appointment within two working days?’ or ‘How long do you usually have to wait between your appointment start time and the time you are seen by your dentist?’^6,7

Satisfaction relates directly to the expectations patients have before they receive any care or contact, and how far that contact meets those expectations. Two individuals can receive exactly the same care, have different expectations, and provide different satisfaction ratings, because of their different perceptions, needs, wants, and motivations.^8,9 This may be related to non-specific and subjective questions such as ‘How do you rate your dentist's caring and concern for you?’ or ‘How happy are you with the care you received?’.^6,7

Patient Reported Outcome Measures or ‘PROM's are tools which assess patients' perspectives on their health-related quality of life at a single point in time and allow healthcare providers to measure how a medical intervention has influenced this. PROMs gather information through short questionnaires which patients are asked to fill in before,¹⁰ and after, their procedure. Any differences in the before and after scores are attributed to the medical intervention.¹¹

Measuring patient experience is now regarded equally as important as clinical effectiveness and patient safety, by healthcare regulators such as the Care Quality Commission (CQC), the healthcare improvement Scotland (HIS) and the healthcare inspectorate Wales (HIW). This is evident through their key lines of enquiry.¹² In dentistry, as in the wider healthcare system, patient feedback has been an important and integral part of service provision,^1,3,4,5 but the question is whether dentists and dental practices in the UK consider the collection of patient feedback to be an important exercise and how often they actually do this? Work is underway to develop dental measures as part of a global initative http://www.ichom.org/

Why should dentists engage with patient questionnaires?

Although no link has been found between patient satisfaction and quality of healthcare service provided, there is evidence of a positive correlation between patient experience and quality.¹³

Although it may not be possible to fulfil the needs or ‘wants’ of every patient, making the effort to ask patients for feedback is still important. This simple process makes it easier for patients and healthcare providers to understand each other and, therefore, work together for health.^14,15 This could have the dual effect of making changes which make patients feel cared for and listened to, and helping dental practices progress their business effectively by making relevant improvements for patients (customers). Whether a validated or locally developed questionnaire is used, or patients are interviewed informally or through focus groups, fundamentally it is the process of asking patients what they think of their healthcare service which is important.¹⁶ In deciding whether to use a validated instrument or not, it is important to keep in mind that the validity of a questionnaire helps the applicators to be sure that the questions they are using are in fact measuring the issues they wish to explore. The reliability, on the other hand, measures the degree to which the questions used in a ‘survey’ elicit the same type of information each time they are used under the same conditions. In summary, a validated and reliable instrument increases credibility and confidence that the feedback received is as robust as possible. The validity and reliability together can be considered the degree to which a survey measures what it claims to measure, avoiding redundancy and repetition.¹⁷ This process has the potential to change a practice from average to good, from better to best and, also, aid patient retention, thus growing the patient base. Improving patient experience by making efforts towards patient-centred care could not only lead to more satisfied and therefore happier patients, but also more fulfilled practitioners and an effective and high quality dental practice.¹⁴

Within the UK healthcare systems (NHS or private), most organizations, including regulators such as the General Dental Council (GDC), Health Inspectorate Scotland (HIS), Healthcare Inspectorate Wales (HIW) and Care Quality Commission (CQC) expect patient surveys to be incorporated into good practice management. In the UK, a variety of questionnaires are in use. Some of these have the advantage of being derived from existing validated questionnaires but tend to be lengthy, whereas others are developed locally, based on what individual practices believe are important questions to ask their patients. There are now organizations, such as Picker,¹⁸ which specialize in developing surveys for healthcare providers. From the literature, no single patient questionnaire has been identified as the ideal instrument for all settings. Some of the more recognized questionnaires being used in the UK and internationally are summarized in Table 1.^{1,2,5,19,20,21,22}

What issues do most questionnaires focus on?

Although there is a wide diversity in the content and format of questionnaires which assess various aspects of patient experience and quality of care, there are common areas which the majority of patient surveys cover. Some of the common lines of questioning include access to dental care and ease of obtaining appointments, and interpersonal skills including communication skills of the treating dentist and the wider dental team.³⁰ Patients are also asked to comment on whether they felt respected and cared for during their contact with the dentist. A community engagement consultation with older people held in London in 2015 found that patients valued care which gave them a sense of ‘warm humanity’.³¹

What are patients most interested in?

A number of studies have explored the fulfilment of patient expectations by comparing patients’ views on ‘ideal’ against ‘actual’ behaviour of dentists. ‘Ideal behaviour’ is equivalent to the ‘desired care’ and a collective summary of patient wants; the research showed that knowledge of patient expectations is important, in that it helps dentists to adapt both the service delivery mechanism and the service outcome to meet expectations, and actively to manage patient experience and satisfaction to ensure that they coincide with the dental care to be provided.^32,33

From the questionnaires cited above, and comparing them with well-established frameworks, such as Maxwell's³⁴ characteristics of access to services, relevance to need, effectiveness, equity, social acceptability, efficiency and economy, as the main dimensions to assess healthcare quality, the attributes which are being assessed most frequently by patients' surveys were extracted.

3. Barriers to dental care

Almost all patient questionnaires include questions relating to barriers to dental care, including specific questions about what would prevent patients from attending for dental treatment. Cost has long been recognized as a barrier to care. However, Sbaraini et al³² found cost to be the least important consideration involved in selecting a dentist. There is evidence that patients who think that the price of dental treatment is too high are often dissatisfied with the quality of service; those patients who were satisfied with the quality of care which they received generally considered the price to be fair.

Dental anxiety and individual perception of need are two further barriers which prevent patients from accessing dental treatment. Dental anxiety and fear of dental treatment are still present in society, affecting adversely the quality of life and dental treatment received by affected individuals.¹⁴ The individual perception of need for dental treatment is also important as many patients who may have active oral disease do not think that they require any dental treatment.^14,33,37

Another important barrier is the attitudes of the dental team towards patients. Dental professionals need to treat patients with respect, communicate clearly, listen carefully to their needs and behave in a way that reflects high standards of professional probity. The lack of these skills may make patients feel confused, vulnerable and discouraged to look for dental treatment. General behaviour of the wider dental team, for example, being courteous, kind, respectful, polite, and being attentive and accommodating with patients' needs can greatly influence how they feel about going back to the dentist.^14,32

Having considered all the important questionnaire domains which are most described in the literature and analysed the content of existing validated questionnaires (Table 1), Figure 1 illustrates the aspects which patients consider most important and shows a set of questions taken from established patient questionnaires. General dental practitioners could refer to these when developing questions for their own patient survey.

How, when, and where should a general dentist carry out patient questionnaires?

This question is answered in Table 2.

How should the results from patient questionnaires be used by GDPs? (Action plan)

The ‘Plan, Do, Study, Act’ (PDSA) cycles³⁹ are stages of change, used as part of a continuous process of improvement.^39,40 The main framework is that a target for improvement is identified, focused and a plan of action established that incorporates opportunity for reflection as part of the whole process (Figure 1). It is grounded in three main issues:

The four stages of the PDSA cycle,⁴⁰ adapted for use by dental practices, are shown in Figure 2. The PDSA model can be used to plan improvements or change work processes. It is essential that all work teams involved are clear about what they want to achieve, how the improvements discussed will be measured, and the need to be explicit about what needs to be changed. Team members should be able and willing to suggest ways of change and show how the proposed modification will improve the service provided to patients.³⁹

During a PDSA model execution, it is common to find resistance to the proposal among the members of the work team. Such resistance can be caused by lack of knowledge and understanding of the change targeted, fear of the unknown, professional autonomy, defensiveness, insecurity and anxiety.⁴¹ Managing, and openly discussing, these concerns during the planning process increases the chances of project success. It is important, therefore, to explain the anticipated benefits of the project to staff. Managers and key leaders should stimulate a culture of openness, involvement and trust, turning team members' responses into learning opportunities.^39,40,41

For the model to be executed successfully in General Dental Practice, all staff members need to be aware of, and committed to, the value and benefits of patient experience questionnaires. Regular staff (team) meetings are essential for achieving this outcome. Managers need to obtain commitment and enthusiasm from all staff with the project, by showing that the process of collecting data from patients and looking at what patients are saying is important and valuable for everyone at the practice. Drawing out common themes from patients' responses and presenting these in a way that the themes can be linked to aspects of care, where practical changes can be made, is most likely to lead to a successful learning and action process. The use of an approach based on SMART goals is desirable, where changes made should be Specific, Measurable, Agreed upon (by all staff members in the practice, patients and regulators), Realistic and Time bound.^40,41,42

Discussion

The results of a questionnaire will depend on the reliability of the response. For example, if a large number of questions have not been answered, it will be important to reflect on why this is the case and consider whether the questions should be removed. Reliability and interpretation of results can be influenced by the timing of presentation of the questionnaire. An immediate response provides a picture of how patients feel at the time of the visit, whereas a delayed response will gives patients time to reflect on their response, within the wider spectrum of their personal and social environments.¹⁷ Discussing the findings through regular planned and scheduled staff meetings and involving everyone in the complete process will identify views of staff on themes identified by patients. In this way, everyone should agree on what can be changed. Staff will, potentially, be interested in hearing what patients have to say and making appropriate changes. This will lead to better communication between staff and patients; and, therefore, improve patient experience when their concerns are addressed in a systematic manner. The process should include both positive and negative comments as a matter of course and all data, comments and actions should be made available to all practice staff^40,41 and, ideally, the responses fed back to patients.

However, compiled feedback in itself is insufficient. What we do with the information afterwards is the factor which will make a difference both to patients and to the dental practice as a business. It is clear from the literature that health services can be improved, and patients can become more compliant, happier, less likely to complain, and more likely to return if they feel that their concerns and comments are being listened to. Therefore ensuring action becomes vitally important, whether this is staff training, better explanations to patients so that their understanding is enhanced or acting on patients' feedback (if patients raise specific issues) for example: improving access to the dental surgery, providing better parking facilities, simplifying how patients make or cancel appointments, introducing a text reminder service or an online appointments system, providing efficient and timely emergency care/appointments, providing more early morning/late evening appointment slots or creating more weekend appointments. The final actions should be relevant to the findings and should be based on improving patient experience and better meeting patient needs.