Larkins, Amy S.; Windsor, Amy V.C.; Trebble, Timothy M.
Understanding patients’ attitudes to their healthcare is essential to developing high-quality 1 patient-centred management. It promotes dialogue between services users, providers and purchasers 2, gives patients a ‘voice’ 3,4 that empowers them in making healthcare choices, can direct service reconfiguration 5,6 and incentivizes quality improvements by recognizing their role as a service evaluator 7. Furthermore, it is essential to understanding patient-reported ‘value’ in the patient journey, which is necessary for lean thinking transformation and other productivity-based service redesign systems 8.
Outpatient management accounts for a high proportion of secondary care resources, with ∼56.3 million clinic appointments per year in the UK 9. Gastroenterology outpatient management relates to a range of subspecialty presentations, and includes chronic disease and functional presentations. It is proposed that patients with gastroenterological disorders have specific needs 10,11 reflecting demographic and clinical disease characteristics. These may differ from nongastroenterological disorders, and result in contrasting patient requirements from and attitudes to their care.
Patient surveys investigating the quality of the outpatient experience are undertaken with the aim of raising standards 12. However, these often have limited value because of poor validity and reliability 13,14, difficulty in interpreting findings and limited translation into service improvement 15. Therefore, it is proposed that understanding quality in the patient experience can be improved by addressing a range of patient-related domains 16, i.e. personal preferences (what should occur, is prioritized or is valued 5), expectations (beliefs about what is desired or will actually occur 5), tendencies due to personal characteristics and quality of care received. Furthermore, that quality in the healthcare experience is measured by investigating whether these (and particularly patient expectations) are addressed 17.
The National Survey of Outpatient in England 12 has been used to identify key domains for a positive patient experience 18 involving patients from unselected outpatient speciality clinics. Published data in the medical literature relating to patient expectations and preferences in gastroenterology outpatient care, however, are limited, with published studies restricted to satisfaction surveys of patients undergoing endoscopic procedures 19,20 or gastrointestinal cancer management 21. Furthermore, there is a paucity of published data in the medical literature relating specifically to patient expectations and preferences in hospital outpatient care from any speciality, with a recent health technology assessment review advising of a pattern of weak research designs, small or selected samples, rarely stated theoretical framework and unclear origins of survey questions with poor validity 22.
This limits our understanding of patient-reported ‘value’ and quality in the gastroenterology outpatient pathway, and therefore how services can be improved and redesigned around patient priorities. The aim of this service evaluation, therefore, was to investigate patient attitudes in gastroenterology outpatients’ care, including preferences and expectations relating to process, environmental and interactive factors. This was intended to test a methodology that can be used for improving quality through informed decision-making.
Materials and methods
Survey design and development
This patient survey was a cross-sectional, self-administered service evaluation of current gastroenterology outpatient care. A structured methodology was followed 2,23.
Domains for the questionnaire were identified from a range of sources. This included four domains from a qualitative assessment of patients’ attitudes of the gastroenterology outpatient experience by two trained junior doctors using open questions, three domains from the national outpatient survey and a report of the key domains associated with satisfaction from the national outpatient survey 12 and three domains from a published, validated endoscopy-related patient evaluation 19,20. These domains and a review of studies from the published literature 24–27 were used to identify aspects of the outpatient pathway that related to experiential quality. A composite, quantitative, self-completed patient questionnaire (Appendix 1) was then designed in two parts. Part one surveyed ‘patients’ expectations of the outpatient clinic experience and was completed by patients while waiting for their appointment, taking ∼15 min. This included demographic details, Likert scale formatted questions relating to attitudes to process aspects of the patients pathway and a 16-point ranking scale questionnaire to determine aspects of the patient journey that patients considered most important in obtaining satisfaction with their visit. Patients’ reported outpatient waiting time and time within consultation were included with their opinion on acceptable durations and influence on satisfaction with their visit. The ranking scale questionnaire was adapted from a validated methodology by Yacavone et al. 20 that had been tested previously for reliability in the local population for patients undergoing endoscopic procedures 19.
Part two of the survey was a retrospective assessment of patient attitudes to the outpatient clinic experience, and included Likert scale formatted questions, completed on exit from their appointment, taking ∼5 min to complete.
The questionnaire was then piloted on 20 patients to review its design for acceptability and appropriateness to the patient cohort. After completing the questionnaire, patients were asked for feedback on how the questions were interpreted and the reasons for incorrect completion, and a preliminary analysis of results was carried out. The questionnaire was adapted as required.
All information was collected anonymously to facilitate open and honest patient responses.
Patient recruitment and survey setting
The survey was conducted in the gastroenterology outpatient department at the Queen Alexandra Hospital, Portsmouth, UK, a large district general hospital that undertakes ∼3500 new referral and 7700 follow-up consultations per year. Consecutive patients attending adult outpatient gastroenterology clinics, varied by specialist, on different days were invited to participate.
The questionnaire used was self-explanatory. Two junior doctors were available to answer general enquiries, although the patients completed the questionnaire independently. Accompanying relatives or friends were allowed to assist patients who were unable to complete the questionnaire because of a language barrier or physical limitations.
Review of previous studies and other sources 28 indicated that a cohort of ∼200 patients would be required. Data entry and statistical analysis was carried out using Microsoft Excel and SPSS 18 (SPSS Inc., Chicago, IL, USA). In view of the nonparametric nature of the results, these were reported as median and interquartile range. The association between expected and postconsultation actual reported waiting times and consultation times were tested using the Pearson’s χ 2-test. The association between patient-reported attitudes to satisfaction and the likelihood of following their treatment plan or attending their follow-up appointment, before and after their consultation, were tested using the McNemar’s χ 2-test.
The survey protocol was reviewed by the NHS Research Ethics Committee, who confirmed its status as a service evaluation for which formal ethical approval was not required. This was consistent with previously published service evaluation surveys in endoscopy 19,29. The basic ethical principles were, however, followed including patient confidentiality.
Between April and October 2011, a total of 236 patients were invited to participate in the survey, of whom 227 agreed, with 210 returning the ranking questionnaire and 190 returning the postconsultation questionnaire. Among responders, 60.4% were women and 39.6% were men, aged between 17.1 and 89.5 years (mean 53.0 years, SD 18.7). Educational status included 5.9% patients who left school before taking GCSEs or O levels, 57.7% after completing GCSEs or O levels, 20.0% after completing A levels and 15.9% who were university graduates.
Patients’ attitudes to waiting room times and their consultation
A total of 14.8% of respondents reported that they were attending hospital outpatients for the first time.
Patients commonly reported that they arrived a median time of 15 min early (range 0–260 min) for their appointment, but that an outpatient waiting time of up to 30 min was reasonable (Table 1). Reported expected outpatient waiting times, however, were 30 min or more in almost half of the cohort (49.6%). By comparison, postconsultation reported actual waiting times showed a greater spread, with both more frequent short waiting times (15 min or less) and long waiting times (greater than an hour), which contrasted with expected values (P<0.05) (Table 1).
When asked who they would like to be seen by, 45.0% of patients responded the consultant, 11.8% any doctor, 5.2% suggested a nurse specialist and 34.5% did not express a preference. When asked what was the minimum time that their doctor or other health professional should spend with them, 86.0% of patients responded ‘as long as necessary’, with other responses as times between 10 and 30 min. The consultation time that patients expected to be spent with their doctor or other healthcare professional and the postconsultation reported actual times are shown (Table 2). Postconsultation values showed a greater spread with more frequent short consultations (less than 5 min) and more frequent longer duration (greater than 16 min), which contrasted with the preconsultation expected times (P<0.05).
Patient responses after consultation
After consultation, 49.5% of patients responded that their waiting room time had been too long and 29.5% as just right. The majority of patients, 68.4%, responded that their consultation time had been ‘just right’, with 5.3% responding that it was too short, 1.6% too long and 24.7% who did not mind or did not express an opinion.
Patient-reported attitudes to their waiting room and consultation times are shown (Table 3). Before consultation, more patients reported that the expected length of time spent in consultation would influence their satisfaction with their visit than would not (43.3 vs. 38.8%). However, this contrasted with postconsultation patient responses, with a majority reporting that their consultation time would not influence their satisfaction with their visit (31.1 vs. 56.9%) (P<0.01). By comparison, there were no significant differences in patients’ reported attitudes with respect to the duration of their consultation times and following their treatment plan (P=1.0) or attending their follow-up appointment (P=0.6).
The results for ranked values for 16 aspects of the gastroenterology outpatient experience that patients considered most important for their satisfaction with their outpatient experience are shown (Table 4). The eight aspects of the outpatient experience considered most important related to the patient–doctor consultation, and included ‘seeing the doctor’, obtaining a ‘clear explanation and questions answered in a way that I could understand’, ‘having confidence in the treatment plan put in place by the doctor’ and ‘being listened to’ (Fig. 1a–c). The eight aspects considered least important related to process or environmental aspects and included ‘involvement of my next of kin in my management plan’, ‘an explanation given for any delay in my appointment time’, ‘appearance and cleanliness of the waiting room’ and ‘length of time I waited to get an outpatients appointment’ (Fig. 1d–f).
This patient service evaluation investigated the nature of quality in a gastroenterology outpatients department. Likert scale questions investigated the relationship between process aspects of the patient journey and their relationship with patient satisfaction, the likelihood of reattendance or adherence to the treatment plan before and after the consultation. A ranking questionnaire was used to prospectively prioritize 16 process, environment and interaction aspects of the outpatient journey with respect to their importance in obtaining a satisfactory experience.
To our knowledge, this survey is the first in the published literature to investigate the interactive, process and environmental aspects of the gastroenterology outpatient journey from a patient value or priorities perspective. The results suggest that aspects of the outpatient visit considered most important for a satisfactory experience relate to the quality of the consultation itself including ‘seeing the doctor’, ‘having confidence in the treatment plan’, ‘clear and appropriately set explanations’, ‘being listened to’, ‘opportunity to express important issues’ and ‘recognition of needs’. By comparison, relatively low importance was attributed to process and environmental aspects including waiting times (appointment and waiting room), explanations for delays and the quietness and privacy of the consultation room, and involvement of the patients’ next of kin. The importance of the nature of the consultation is supported by a clear preference from patients that the minimum time for the consultation should be as long as necessary and, in the majority of responses, by the consultant.
Patient attitudes to the duration of steps in the patient journey were included as a reflection of the quality of its process. The outpatient waiting room times were reported as too long at an hour or more in over 40% of patients; however, it is not clear whether this represented time from patient arrival to the department or time from the allotted appointment time or whether they were subjective estimates or recorded. However, after consultation, the outpatient wait duration was more commonly not considered important in influencing satisfaction with the outpatient visit. In addition, patients commonly reported that consultation times were of acceptable duration, albeit contrasting with their expectations, and did not appear to alter their satisfaction with the outpatient experience. The pattern of these responses may indicate that satisfaction with the outpatient experience is more reflective of qualitative aspects of the patient–doctor interaction (as identified in the ranking questionnaire) than process (including waiting and consultation times) and environmental aspects.
A central component of the methodology was to achieve validity and reliability in the survey. The questionnaire used established formats including Likert questions and a ranking system that had previously shown construct validity for satisfaction among patients undergoing endoscopy in the USA and was further assessed for reliability in the local population 19, with domains for the ranking questionnaire derived from a combination of available sources. The questionnaire was subjected to further review with respect to patient interpretation of the questions and a pilot study, before its full use. To reduce selection bias, consecutive patients from various gastroenterology clinics on different days were evaluated, although a formal randomization process was not used. Selection bias is also likely to have been reduced by the relatively high return rate on the patient questionnaire of over 80% across its composite parts. To reduce acquiescence response bias 15, all patient interaction in the evaluation was undertaken by two junior doctors without any other involvement in outpatient management and with strict patient anonymity without recording of names or any other identifiable details other than date of birth (to determine patients’ age).
Previous surveys of patients attitudes to outpatient care have utilized a number of different methods, but there has been a recognized failure to identify an optimum system 30, with studies frequently based on poorly validated satisfaction surveys 13, with limited interpretability 16 because of their subjective, multidimensional nature 2. By comparison, the service evaluation described did not assess patient satisfaction but aimed to identify domains associated with a quality and satisfactory outpatient experience that may be used to facilitate service improvements and redesign around patient priorities 14 through lean thinking 31 and similar transformation systems. These data can also be used to determine and address patients’ preferences and expectations, which can positively influence their opinions of the healthcare they receive, their engagement with doctors and clinical management 32–34.
The findings reported are consistent with the key domains as predictors of patient experience noted in the national surveys of outpatient experience in England 12 that included ‘dealing with the issue’, ‘doctors’ and ‘information about discharge and treatment’. A questionnaire study of cardiology and GP clinic outpatients using Likert scale questions only (without ranking of importance or value) noted that patient expectations related to interactive factors with their doctor in consultation but also process and environmentally related factors including waiting times and cleanliness 22. The role of the interactive factors in determining quality in the outpatient journey was also noted in a meta-analysis by Saila et al. 30 that identified the importance of the consultation with the doctor, effective communication and the establishment of a trustful yet professional patient–doctor relationship. Our findings contrast with the results of studies that have placed an emphasis on process aspects of the outpatient journey including waiting times for a first appointment and in the waiting room 25 and time in consultation 35. By comparison, published studies in oncology patients suggest that waiting times, environmental factors and aspects of patient–doctor interaction 36 may all be relevant to a satisfactory experience. These studies differ from the current service evaluation by reviewing aspects of care in absolute terms, and not comparatively, and therefore cannot be used to determine those steps within the pathway that patients prioritize and that reflect the greatest value in their healthcare journey. However, it is recognized that the nature of the process and environment involved in the patient pathway can also influence the quality of the consultation even if considered of low relative importance, for example by limiting patient–doctor interaction 37.
What does this mean for doctors, their patients and service development? Three initial conclusions can be made. First, the focus of service development should be the quality and nature of the outpatient consultation, addressing patients’ needs, and facilitating doctors in achieving this. By comparison, environmental and process issues may be a lower priority, and in addressing any related issues, care should be taken to avoid a detrimental effect on the nature and quality of the consultation. Second, the results suggest that shorter consultation times and longer outpatient waiting times are unsatisfactory for patients. However, their overall influence on patients’ satisfaction with the outpatient experience may be less important than whether their expectations of the qualitative aspects of the doctor–patient consultation were met. Third, outpatient evaluations should be designed around patient priorities in their healthcare journey, which can be identified clearly through a patient survey.
The study was carried out as a service evaluation in a single centre, the results of which indicate the need for larger formal studies in both gastroenterology and other specialities. If replicated in alternative settings, this may indicate a need to review how we investigate and address patient attitudes to their outpatient care in gastroenterology and more broadly in healthcare.
The authors thank Steve Sizmur, Senior Statistician, Picker Institute, Europe.
Conflicts of interest
There are no conflicts of interest.
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