Professional development
What can patient surveys really tell you?
The right focus may help you prove your value
No matter what your practice setting, as a case manager you have the ability to influence customer satisfaction with your organization. If you provide those additional resources that help your patient understand what will happen next, where to turn for advice, what insurance benefits cover, or how to comply with physicians’ orders, you can positively influence that patient’s perspective, whether you work for an inpatient facility, home care agency, or payer.
More importantly, if you regularly measure patient satisfaction with your performance and use the data from those surveys to improve that performance, suddenly you have a powerful tool to prove your value to your organization. However, case management organizations will find the results of a patient satisfaction survey to be useful only if they make sure the survey is valid, reliable, and highlights areas that can be targeted for quality improvement, says Jan Brien, MS, director of Parkside Associates in Park Ridge, IL. Parkside Associates, which specializes in patient, physician, and employee surveys that guide and evaluate quality improvement programs, has provided surveys and research services to more than 600 health care organizations nationwide.
Use valid, reliable surveys
As an example of the data health care organizations can glean from patient surveys and how they can use it, Brien cites a recent Parkside, 183-agency patient satisfaction survey of 16,727 home care patients. Overall, 64% of the respondents said their home care experiences and quality of care were "excellent." Only 2% called their home care services "poor" or "fair."
However, the survey did highlight areas that needed improvement. For instance, the survey found that home care patients expressed more satisfaction with the area of care process than with the education process. Patients largely were satisfied with the amount of time a home care employee spent with them, made them feel at ease, or showed concern for them. Patients were a little less satisfied with how the staff involved them in the care decision and goal-making process. They also expressed less satisfaction with how home care staff encouraged questions and explained medications and procedures.
"It’s important to note that the care process and patient involvement are the two areas that have the most impact on how patients rate overall quality of their encounter," Brien says, adding case managers influence those areas directly.
Help patients understand
An organization that finds these types of discrepancies in a patient satisfaction survey could easily target patient education in a quality improvement project. However, case managers face an additional obstacle because few patients understand who the case manager is or what he or she is responsible for, says Brien.
"On our inpatient surveys, we often use different terminology for questions about the same role or function. For example, we might ask patients how helpful they found the social worker/discharge planner/case manager.’ It’s simply that patients often don’t have a clear understanding of who’s accountable for different aspects of their care," she explains. "Our job — and yours, when you measure patient satisfaction with your performance — is not to educate patients about the role of the case manager but to measure their satisfaction with the functions the case manager is responsible for.
"Not every survey effectively measures quality improvement," Brien says. "You need to make sure you’re working with a good questionnaire to begin with." This is not as easy as it sounds. She suggests following these guidelines:
• Make sure there’s evidence for reliability and validity in the survey. Reliability and validity are related to the type of scales included on the survey. The survey questions should cluster to form scales, and the scales should be reliable, Brien says. "That means the items within the scales should have strong evidence of internal consistency, which is the appropriate statistical term for multi-item scales," she adds.
• Include at least two items on your scale. Often, the more items included on a scale, the stronger the reliability will be. However, there are exceptions: One of the scales on Parkside Associates’ home care survey has only two items, yet it is very reliable, Brien notes.
The entire home care survey has four scales, which are the care process, patient involvement and education, orientation to home care, and perceived medical outcome.
Validity refers to how well each of these scales predict overall quality of care because improving quality is the survey’s goal.
• Create an effective sampling method.
The sampling method should be determined by your overall plan for analyzing data. For example, a large health system may have case management services at more than one facility. In that case, you may want to look at client satisfaction in various sites, and you should stratify your sample by site.
Parkside Associates had the home care agencies in its 183-agency study send out 300 customer satisfaction surveys. The average rate of return was 53%.
• Make sure the sample size is adequate for an analysis. Sample size adequacy is determined by the estimated number of errors. The larger the sampling size is, the smaller the chance of error affecting the results will be. Brien says a mailing of 300 surveys with a 53% response rate is large enough to yield a low level of error.
Case management organizations can follow several strategies to make sure they have an adequate response rate, which typically would be in the 40% to 50% range. Mailing is an inexpensive way to distribute surveys, but it often yields a low return rate, she notes. To increase your response rate, she suggests these methods:
• Send the survey within one week of a patient’s discharge and send a follow-up letter a week later.
• Follow up nonresponders with a telephone call.
• Set up a system to prevent over-sampling, or sending repeat surveys to the same patients.
Brien recommends you send a survey to a patient only once in a six-month period. "It might be difficult to track that, to pull the samples, but that really can affect the response rate."
Don’t overanalyze the survey results
"When you create a report on your survey, only do the analysis you need," Brien says. "Sometimes people overanalyze the results when they should just get the key information, no more and no less, and it should be understandable because understandable equals usable."
To integrate satisfaction results into a quality improvement or continuous quality improvement process, she has four recommendations:
1. A survey that pinpoints a key aspect of service will identify an important customer requirement.
2. A survey that monitors satisfaction levels over time can determine if any changes need to be made or if patient satisfaction has improved or declined as a result of new policies.
3. Surveys can help evaluate the effectiveness of quality improvement efforts or the value of new services.
4. Survey results can be used as a part of your employee compensation and incentive program. The better the satisfaction rating, the better rating the case manager might receive on an annual review. Or a whole department might receive a financial reward if patient satisfaction measures improve.
"It’s important to keep careful watch over the outcome of care that’s provided to your patients, because one outcome is their perception of the care," Brien says. "If you’re doing continuous quality improvement initiatives, then you want to measure the impact of your initiatives."
Chart your own success
Brien says one case management organization cannot "photocopy" the success story of another because quality improvement doesn’t always work the same for different organizations. However, if you identify a potential problem area based on patient satisfaction surveys, there are some basic steps you could take to solve the problem.
For example, she says, suppose your patients expressed some dissatisfaction with the amount of information they received about follow-up care. The first thing a case management organization should do is create an communication flowchart that tracks the type and timing of information case managers share with patients.
"The patient satisfaction survey is only the first step," she explains. "It’s a useful tool that may set off red flags in those areas needing improvement."
Before you make a leap and plan an intervention, chart your current process, she says. To prove their effectiveness, case managers must follow an organized quality improvement process. For example, Brien says, a systematic quality improvement approach to a communication flow problem might include the following steps:
• Chart your pre-intervention patient communication process.
• Measure your baseline satisfaction rating with patient/case manager communication flow.
• Identify opportunities for improving communication with patients.
• Create new communication flowchart that includes interventions to problems identified in previous step.
• Distribute and explain new flowchart to all case managers.
• Measure your patient satisfaction rating four months after the intervention.
"If your patient satisfaction rating improves, you now have a tool you can take to your upper-level management and say, We did a good job. We intervened. We saw holes case management could fill and filling them made a difference to this organization.’"
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