Setting priorities for improving the preoperative assessment clinic: the patients' and the professionals' perspective

Abstract

Background

The quality of the preoperative assessment clinic (PAC) is determined by many factors. Patients’ experiences are important indicators, but often overlooked. We prepare to set priorities to improve the PAC by obtaining detailed patients’ feedback on the quality of the PAC, and establishing the value patients and professionals attach to different care aspects, using the Patient Experiences with the Preoperative Assessment Clinic questionnaire.

Methods

The PAC’s standard of service was determined for five care aspects (dimensions), using patients’ feedback. The importance of a dimension to patients was determined by calculating the effects of the dimensions on patients’ overall appraisal. In addition, professionals were asked to rate the importance of the different care aspects.

Results

Patients had the most positive experiences with the nurse, and the least positive experiences with waiting. However, waiting was least important to patients. When combining the PAC’s standard of service with the value given to the dimensions by patients and professionals separately, we found in both instances that waiting was in greatest need of improvement. This was followed by reception, the anaesthetist, remaining experiences, and finally the nurse.

Conclusions

Quality improvement of the PAC can be achieved by obtaining patients’ feedback on the quality, determine a PAC’s standard of service, recognize service areas that require improvement, and identify actions appropriate to bring about improvement. The value patients and professionals attach to different aspects of care can then be used to prioritize improvements.

In the nineteenth century, Florence Nightingale already stated that ‘were there none who were discontent with what they have, the world would never reach anything better’. Yet not until recent years are patients’ complaints, views and perceived priorities being used to help shape health care services and to improve the quality of care. Obtaining feedback from patients can help to identify the areas that are (not) performing well and the areas important for care quality improvement.^1–3

Performing surveys to obtain patients’ views on their health care experiences is customary in Britain, where national surveys of the National Health Service (NHS) are carried out by the Commission for Healthcare Audit and Inspection. Patients’ experiences with the preoperative assessment clinic (PAC) have hardly been studied. We previously developed and validated the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire, an in-depth questionnaire, to objectively measure patient experiences with the PAC.⁴ This questionnaire was used to determine the patients’ view of our PAC.

At the same time, the professionals’ perspective warrants attention when changing health care services. Given that their input and energy is needed, and their views are relevant, it is important to take their values into account when planning to implement care improvement.⁵

The aim of the present study was to set priorities to improve the quality of the PAC by obtaining patients’ feedback on the quality of the PAC and establishing the value patients and professionals attach to different aspects of care.

Methods

The PEPAC questionnaire

In a previous study⁴ we described the construction and validation of the PEPAC: a questionnaire to measure patient experiences with the PAC. It consists of 72 report style items with multiple response options, based on the NHS outpatient questionnaire.⁶ The response options of each item were transformed to a score from 0 to 100, with 100 representing the most positive experience and 0 the most negative experience. The questionnaire has five dimension scales to measure five care aspects, i.e. reception (3 items), waiting (6 items), the nurse (5 items), the anaesthetist (20 items), and remaining experiences (15 items). In addition, patient’s overall appraisal of the PAC was measured, using a separate scale consisting of seven items.

The patient survey

In May and June 2006, the PEPAC questionnaire was sent to 700 consecutive patients who visited the PAC at the Academic Medical Centre, Amsterdam. Patients from all surgical specialties were included in our study; children under the age of 16 were excluded. According to Dutch regulations no formal approval is needed for studies with non-invasive interventions, such as surveys. The Hospital’s Medical Ethics Committee confirmed that our study was indeed excluded from its approval.

The professional survey

To establish the value professionals attach to different care aspects, professionals were asked to rate the importance of the items of the PEPAC questionnaire, using a 3-point scale (1, very important, 2, somewhat important, and 3, not so important). The questionnaire was given to 66 professionals: 30 residents of the department of anaesthesiology, 33 anaesthetists, and all 3 nurses who work at the PAC.

Analysis

Patient characteristics and missing values are determined using descriptive statistics. Comparisons of characteristics between respondents and non-respondents were performed for gender, American Society Anesthesiologists’ (ASA) physical status and inpatient vs day case surgery by Fisher’s exact test and for age by Student’s t-test.

The PAC’s standard of service was determined by patients’ dimension scores: the average of patients’ scores on the items in a dimension (range 0–100).⁴ A high dimension score indicates good experiences with the service.

The importance patients attach to a care aspect was determined through regression analysis, with patients’ overall appraisal as the dependent variable and the dimensions of the patients’ experiences as independent variables. The dimension with the largest standardized regression coefficient was considered most important to patients.

Alongside patients’ evaluations, we determined the importance of a dimension to professionals. First, we calculated the mean professionals’ importance rating of an item. Subsequently, the importance of a dimension was determined by averaging the professionals’ scores of the items in a dimension. As on the 3-point scale used, one represented very important and three represented not so important. The dimension with a score nearest to one was most important to professionals.

Finally, in order to enable a comparison between patients’ and professionals’ importance ratings, the standardized regression coefficients (patients’ importance ratings) and the professionals’ importance ratings were each transformed to ‘weights’ that sum to one. To set priorities for improvement from both patients’ and professionals’ perspective, the dimension’s mean standard of service was subtracted from 100 and multiplied by the weight. The dimension scoring highest after these multiplications is in the greatest need for improvement and therefore has the highest priority.

Results

The patients

The PEPAC was returned duly completed by 519 patients (74%). Table 1 shows patients’ socio-demographic characteristics. On average non-respondents were younger than respondents (51 vs 44 years; P<0.001); there was no difference with respect to gender or ASA physical status (Table 1). Day case surgery patients were less likely to participate (P<0.001) (Table 1).

The highest standard of service was found for the dimension the nurse with a mean dimension score of 91 (sd 10); waiting was judged as having the lowest standard of service with a mean dimension score of 49 (sd 19)⁴ (Tables 2 and 3). The mean individual item scores ranged from 21 to 98 (Table 2).

The dimension remaining experiences had the largest standardized regression coefficient 0.556 (se 0.037) and thus was most important to patients. Waiting was least important to patients with a standardized regression coefficient of 0.419 (se 0.041) (Table 3).

The professionals

The questionnaire was completed by 49 professionals (74%): 24 residents (80%), 22 anaesthetists (67%), and 3 nurses (100%). Generally, all items and dimensions were deemed quite important by the professionals, with the mean importance score ranging from 1.13 for the nurse (most important) to 1.54 for remaining experiences (least important) (Table 3).

Priorities for improvement

To set priorities for improvement, the PAC’s standard of service was combined with the value given to the dimensions separately by patients and professionals. We found that in both instances waiting had the greatest need for improvement, followed by reception, the anaesthetist, remaining experiences, and finally the nurse (Table 3). Table 2 shows that all items that scored <60 concern informing patients or giving them a choice.

Discussion

In this study, we set priorities to improve the quality of the PAC by obtaining patients’ feedback on the PAC’s standard of service and establishing the value patients and professionals attach to different care aspects. In nearly all commercial fields, the importance of consumer judgements has been recognized. However, the health care industry has been relatively slow on the uptake of the importance of patient judgements. Traditionally, its focus was exclusively on diagnosing and treating the patient, and not on the circumstances under which this took place. The quality of health care was mainly assessed by medical outcomes: a concrete indicator of quality.⁵ However, medical outcomes do not include all aspects of health care. In recent years, it has been acknowledged that non-medical issues are of great importance to patients, and patient experiences can be used as an indicator for the quality of health care.⁷ Therefore, patients’ views and perceived priorities are being used to help improve health care services.^1,8–11 However, up to now this strategy has not been employed to improve the quality of the PAC.

To set priorities for improvement, we combined patients’ feedback on the quality of the PAC with the value given to different care aspects by patients and professionals separately. We found that from the patients’ and professionals’ perspective the priority setting was similar. For the greater part the priorities for improvement were determined by the quality of the PAC, i.e. the standard of service, as the weight given to the five care aspects did not differ greatly, neither for the patients nor for the professionals. Waiting had the highest priority for improvement. In concurrence with Hepner and colleagues¹² we found the lowest mean dimension score, i.e. the lowest standard of service, for this dimension.

Fung and Cohen¹³ found that anaesthesiologists were unable to predict what outpatients value most in their anaesthesia care. Our study also shows that patients and professionals value various aspects of care differently. There are a few notable differences. Patients deemed the dimension remaining experiences most important, while professionals regarded this dimension as least important. Professionals considered the nurse the most important dimension, whereas patients regarded three other dimensions more important (Table 3).

Often other factors can be taken into consideration when setting priorities for improvement. Some improvements are more difficult to attain than others. It is also possible to start with quick wins: improvement plans that can be implemented at low costs in a relatively short period of time. Improving patient flow logistics to reduce waiting times is a costly and timely matter. However, it is not necessarily the most effective way to improve this dimension. Our results indicate that simply informing patients about the length and the reason of the waiting time would increase the standard of service of this dimension greatly.

To what extent our results can be extrapolated to other institutions is difficult to ascertain. Slight adaptations to the PEPAC might be necessary as the organization of PACs is not uniform. Standards of service will differ, as might the value attached to different aspects of care by patients and professionals. However, the same method to set priorities for improvement of the PAC can be used elsewhere.

A striking result is that all items that scored <60 concern informing patients or giving them a choice, emphasizing that patients deem information and communication very important.¹² The standard of service of all dimensions could improve by informing patients better. Informing patients about what will happen at the PAC might improve reception. Notifying patients about the length and the reason of the waiting time could improve waiting considerably. The dimension score for remaining experiences might rise by giving patients a choice of appointment dates and times, and giving them a brochure with information about the PAC. The anaesthetist should provide more information, especially on what happens in the operating room, risks and side effects of anaesthesia, pain control, medication, and fasting (Table 2). Whether the actions proposed to bring about improvement improve the dimension scores is a further empirical question.

Study limitations

We set priorities to improve the quality of the PAC by obtaining patients’ feedback on the quality of the PAC. The quality of the medical assessment could not be taken into account, as this is not easily judged by patients. Instead, the focus was on the circumstances under which the assessment took place.

Non-response can result in some bias of the results as older patients are inclined to report somewhat higher satisfaction with care.¹⁴ In our study, the average age was slightly higher for the respondents in comparison with the non-respondents and may have resulted in slightly more positive scores in our study. However, since our response rate is high (74%), we do not expect such bias to have a large influence on our conclusions.

We did not ask patients directly to rate the importance of the items of the PEPAC questionnaire, as the questionnaire was lengthy already. Instead, we used statistical analysis to determine patients’ priorities. It would be interesting to validate patients’ importance ratings of the items in a separate study, using the same 3-point scale (1, very important, 2, somewhat important, and 3, not so important) given to the professionals.

In conclusion, the quality of the preoperative assessment at the PAC is determined by many factors. Often, the focus is mainly on the medical assessment. Patients’ experiences with the PAC are also important and should not be overlooked. The quality of a PAC can improve by obtaining patients’ feedback on the quality of the PAC. Their feedback can be used to determine a PAC’s standard of service, to recognize service areas that require improvement, and to identify actions appropriate to bring about improvement. Concrete measures like informing patients about the length and the reason of the waiting time. The value patients and professionals attach to different aspects of care can be used to prioritize the improvements. The PEPAC questionnaire is a valuable tool in this process.

Funding

Support was provided solely from Institutional and Departmental sources.

References