Quality Improvement in Primary Care

The Essential Guide

Stephen Gillam, Niro Siriwardena

• Publisher: CRC Press
• Year: 2022
• eBook ISBN: 9780429533525
• Edition: 1
• Topic: Business
• Subtopic: Family Medicine & General Practice
• Index: Business

This book provides readers with an invaluable set of tools to convert the endless challenges for quality and myriad opportunities for improvement into meaningful and useful change. It considers how to manage primary care organisations in order to improve quality of care; how general practices are regulated and held accountable; various techniques used for assessing and measuring; and commonly used quality improvement frameworks.

SECTION 1 Managing for quality

DOI: 10.1201/9780429084041-2

CHAPTER 1 Patient perspectives

DOI: 10.1201/9780429084041-3

SUMMARY

• Perspectives of service users, patients and carers, and the public are central to quality improvement in healthcare.
• Service users are increasingly involved in generating information to guide others seeking healthcare, helping to determine needs or preferences in healthcare choices, and providing feedback on health services.
• Measures of patient satisfaction, patient experience and patient-reported outcomes are closely related but different ways of expressing the quality of health services from a patient perspective.
• The different methods of collecting patient and carer feedback - including surveys, measures or interviews - have advantages and disadvantages.
• Patients and the public will in future have greater involvement in commissioning, monitoring and regulation, with an increasing role in improving and redesigning health services.

THE PATIENT PERSPECTIVE

In this first chapter we focus on patient perspectives on healthcare quality improvement and how we might involve patients, carers and the public in developing our notions of quality, in supporting quality improvement efforts, and in monitoring and regulating services. Throughout this book we will emphasise the primary importance of patients' perspectives on quality. Indeed, it could be reasonably asked, what perspective of quality is there other than the patient viewpoint, whether this relates to the care that the patient experiences or the clinical outcomes that result?

Joseph Juran defined quality in two ways: first, 'those features of products which meet customer needs and thereby provide customer satisfaction'; second, 'eedom from deficiencies' (Juran and Godfrey 1999). However, Deming (1982) makes the point that quality depends on who is the judge of quality. In the case of healthcare this could be the patient, healthcare professional, manager, organisation, commissioner, inspector or regulator, each with his, her or its own perspective. As information about healthcare interventions, professionals and organisations improve, as it becomes more available and presented more clearly, and as public involvement at various levels increases, service users will play a greater role as judges of quality.

Understanding what service users value is therefore necessary, but not always sufficient, for knowing where we should focus quality improvement efforts. Just as importantly, service users should be involved in how we should bring improvement about or judge whether it has been achieved. This requires a major shift in our thinking from patients being (passive) recipients of care to being (actively) involved in informing and improving seivices.

Unfortunately, in the past, quality and improvement efforts in healthcare have focused on what professionals think patients should value, and have been less interested in what service users themselves feel is important or have failed to elicit patients' views directly. Professional perspectives are a proxy for that of the patient but there may be occasions where the two diverge and the reasons for this need to be understood.

Recent major failures m health services - for example, those described in the Francis report, detailing widely publicised failures at a hospital in Stafford in central England - have reiterated the importance of the patient perspective (Francis 2010).

To quote Robert Francis QC:

[It is the] individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented. (Francis 2010)

Clinicians, managers or commissioners of services may all try to see issues from the patient perspective and claim to represent patients. However, the focus of this chapter is the involvement of service users themselves and their representatives in measuring satisfaction, experience or outcomes, in making judgements about the quality of services, and in designing improvements in healthcare.

Points to ponder

• How do you currently gather information on patient preferences, satisfaction, experiences and outcomes for your service?
• How would you describe the most recent judgements from service users on your service, and what was your response?

QUALITY FRAMEWORKS AND PATIENT VIEWS OF SERVICES

Many well-known quality frameworks highlight the importance of patient experience. For example, the US Institute of Medicine, in their landmark monograph Crossing the Quality Chasm: A New Health System for the 21st Century, referred to patient-centredness together with safety, timeliness, effectiveness, efficiency and equity as the fundamental components of quality (Institute of Medicine 2001). 'Patient-centredness' is a complex term that means different things to different people (Siriwardena and Norfolk 2007), but in this context it refers to respect for an individual patient's culture, social context and specific needs and it encourages the patient to be active in decisions about his or her own care.

In the UK, efforts are being made to identify and address the key quality issues for health systems in terms of the triad of safety, effectiveness and experience (Darzi of Denham 2008). This has led to a renewed focus on improving patient outcomes (Department of Health 2010). The National Health Service (NHS) Outcomes Framework has 'ensuring people have a positive experience of care' as one of five outcome domains (Department of Health 2013b). The NHS Constitution lays down the rights (and responsibilities) of its patients and staff in order to achieve this (Department of Health 2013a). Recent studies have suggested that there is a consistent positive relationship between patient experience, effectiveness and safety (Doyle, et al, 2013), reinforcing the importance of patient experience as part of the quality triad.

More recently, in response to the review of failures at the Mid Staffordshire NHS Foundation Trust, Don Bewick and the National Advisory Group on the Safety of Patients in England, in their publication A Promise to Learn - a Commitment to Act: Improving the Safety of Patients in England, expressed that patients and carers should be present, powerful, and involved at all levels of healthcare organisations (National Advisory Group on the Safety of Patients in England 2013). Finally, the Keogh review, or Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England, stated that we should involve patients, carers and members of the public as vital and equal partners in design of services and involve patients and clinicians as active participants in regulatory inspections (Keogh 2013).

Points to ponder

• What have been the recent failures in the service you provide or in provision of services you were aware of?
• What were these failures due to and how might they have been prevented?
• What might the role of service users have been in preventing failures and how could service user input be better used in future?

PATIENT PREFERENCES, SATISFACTION, EXPERIENCE AND OUTCOMES

Patient preferences, satisfaction, experience and outcomes (see Table 1.1) are overlapping but not identical concepts. Satisfaction and experience are both expressions of 'utility' or 'happiness' with services provided. Of course, many people prefer not to use services unless they have to.

There are many ways of eliciting patient views, ranging from those such as surveys or questionnaires, which attempt to provide a broader more representative assessment from the population being sampled, to interviews, focus groups and patient stories, which try to gain a more in-depth understanding. Other methods that provide lesser degrees of breadth and depth of views include online ratings, 'mystery shoppers', complaints and compliments from patients, relatives or friends, feedback from patient liaison services or patient participation groups, and public meetings (De Silva 2013).

Patient satisfaction surveys are regularly undertaken in most health settings and are intended to provide a quantitative (and often representative) assessment of satisfaction with services in a number of domains. For example, the general practice patient survey linked to the Quality and Outcomes Framework (Gillam and Siriwardena 2010) covers areas such as access (telephone, face-to-face, in-hours, out-of-hours), continuity, communication, care (from the

TABLE 1.1 Measuring patient preferences, satisfaction, experience and outcomes

	Preferences	Satisfaction	Experience	Outcomes
Instruments	Interviews, focus groups, surveys, consensus methods [nominal group, Delphi), or experiments (e.g. discrete choice experiments]	Satisfaction survey	PREM; interviews or narrative interviews (patient stories)	Patient-reported outcome or outcome measure
Timing	Before or after	After	After	After, when compared with threshold score, or before-arid-after
Advantages	Help inform decisions about provision of services	Easy to administer and analyse	PREMs easy to administer and analyse; interviews	Valid and reliable outcome measures are available for a range of conditions or generic health status (e.g. EQ-5D)
Disadvantages	Problematic when trying to elicit future needs or preferences; results can vary according to method and population	Poorly constructed questions, selective distribution and/or low response rates can lead to bias; positive overall ratings can mask significant problems of experience	Expensive to develop valid and reliable PREMs or to conduct and analyse interviews; poorly constructed questions, selective distribution and/or low response rates can lead to bias	Expensive to develop valid and reliable measures, and to administer and analyse; many conditions do not have appropriate measures developed

PREM = patient-related experience measure

general practitioner, nurse or recep...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Foreword
• Foreword
• About the author
• Introduction
• Section 1: Managing for quality
• Section 2: Tools for improvement
• Section 3: Evaluation and personal development
• Conclusion
• Additional online resources
• Glossary
• Index