545124
research-article2014
AJMXXX10.1177/1062860614545124American Journal of Medical QualityMohammed et al
Article
Creating a Patient-Centered Health Care Delivery System: A Systematic Review of Health Care Quality From the Patient Perspective
American Journal of Medical Quality 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614545124 ajmq.sagepub.com
Khaled Mohammed, MBBCh, MPH1, Margaret B. Nolan, MD1, Tamim Rajjo, MD2, Nilay D. Shah, PhD1, Larry J. Prokop, MLS1, Prathibha Varkey, MD, MPH3, and Mohammad H. Murad, MD, MPH1
Abstract Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes. Keywords patient perceptions, quality of health care, health care delivery, systematic review, meta-narrative review
Patient experience has gained greater emphasis with the recent introduction of the value-based purchasing (VBP) program implemented by the Centers for Medicare & Medicaid Services. Patient experience is one of the 3 key domains of VBP (the other 2 domains are clinical process of care and outcomes) and accounts for 30% of the total score that determines hospital payment. Similar measures are being developed for physicians and health systems. The focus on patient experience reflects the broader emphasis and movement toward patient-centered care delivery and emphasizes the fact that patients’ care should encompass not only the outcomes of care but also their personal experience of that care. Typically, patient experience is measured using surveys of patient satisfaction after an encounter with the health care system. Patient experience measures can provide robust measures of quality and can capture patient evaluation of care focused on communication with the delivery system.1 Although patient experience surveys have limitations, patient experience data can be used to improve the delivery of health services and patients’ perceptions and experiences with care, and also has the
potential to improve patient outcomes. Furthermore, identifying and improving patient experience of care is a key component of enhancing the value of the health care delivery system for consumers. Although standardized measures of patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are used for performance measurement and payment, prior studies of patient satisfaction have suggested that patients have a complex set of beliefs and expectations about their health care, which may not be represented in traditional patient satisfaction measures.2 Moreover, patients’ assessment of quality is not always aligned with that of providers at the same institution.3 There may be areas of care delivery or 1
Mayo Clinic, Rochester, MN Mercy Family Medicine Residency Program, Toledo, OH 3 Seton Healthcare Family, Austin, TX 2
Corresponding Author: Khaled Mohammed, MBBCh, MPH, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Email: [email protected]
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The quality of health care?
Perceived by health system providers (not within the scope of this analysis)
Perceived by paents
Main Queson: What are paent percepons of high-quality health care? Percepons mapped/converged into discrete dimensions
• • • • • • • • • •
Communicaon Health care access Shared decision making Provider knowledge and skills Physical environment Paent educaon Electronic medical record Pain control Discharge process Prevenve services.
Secondary exploraon: Do dimensions differ by seng/condion/geographic locaon?
and terms. The different terms (here, patient perception of quality) are categorized thematically by independent reviewers. New categories are created until saturation (no new themes are identified). Occasionally, subgroup analysis (inferences based on different settings or populations) can be possible. The methodology and phases of a meta-narrative review are displayed in online supplementary Table 1 (available at http://ajmq.sagepub.com/ supplemental).
Study Eligibility Inclusion Criteria. All studies about patient or consumer perceptions of high-quality health care were included regardless of type of study design (eg, randomized, observational, survey, descriptive, qualitative), population, age, sex, morbidity, or setting (eg, inpatient, outpatient, emergency care). Exclusion Criteria. Nonoriginal, summarized literature, opinions, and educational materials were excluded, as were non-English studies.
Figure 1. Analytic framework.
Literature Search deficiencies in care that may cause dissatisfaction to patients but remain invisible to providers. In addition, there may be a number of other factors, not measured by patient satisfaction or experience, that affect how patients view the quality of a health care system and how they choose where to receive their care. More recently, other modes of capturing patient assessment and experience at individual health care organizations have been developed through common Web sites and applications such as Yelp.4 Therefore, the research team conducted a systematic review of the published literature to better understand the factors that affect patient perceptions of health care organizations. The aims of the study are to explore patient perceptions of quality of health care and to understand how patient perceptions may differ by settings and condition.
A comprehensive search of several databases from 1995 to February 2014 was performed by a reference medical librarian. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Google, and Scirus. Controlled vocabulary and keywords were used to search for terms describing health care quality, health care value, delivery of health care, health care marketing, combined with patient/consumer perceptions, experiences, perspectives, and satisfaction. The search results were visually scanned for relevant articles and Web pages. The detailed search strategy is provided in online supplementary Table 2 (available at http://ajmq.sagepub.com/supplemental).
Methods
To look for the relevant information in sources not published in the biomedical databases, general Internet searches were conducted in duplicate (KM, MN) using Google and Bing. Modified search terms from the biomedical databases search were used. The links were examined until 20 nonrelevant links were identified using saturation and the snowballing approach.
This systematic review was conducted based on the analytic frame work depicted in Figure 1. The meta-narrative approach was followed, as suggested by Greenhalgh et al,5 in which a multidisciplinary team is formed to develop an a priori protocol that includes explicit criteria for study selection and inclusion, plans for data extraction and analysis, and finally to produce inferences or recommendations. This approach is usually followed when the research question is anticipated to be answered by heterogeneous studies that describe different outcome measures
Environmental Scan
Study Selection Two reviewers (KM, MN) independently identified eligible studies by reviewing abstracts and full-text manuscripts.
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Mohammed et al Disagreements between reviewers were reconciled by discussion, consensus, or arbitration by a third reviewer (MHM).
1567 Citations obtained by the search strategy
Quality of Studies Assessment To assess the risk of bias, the research team evaluated adequacy of patient selection, respondent rate, and the use of validated instruments in measuring the targeted outcome.
Data Extraction
1517 Citations excluded by screening titles/abstracts
50 Full-text articles assessed for eligibility
15 Citations obtained by environmental scan
Two reviewers (KM, TR) extracted the data from each study independently. Data extraction forms included the following variables: study population, study setting, study location, study objectives, type of study design, sample size, instruments used in measuring quality perception, patient perception of quality of health care, main finding, and study conclusion.
29 Articles excluded: (No relevance to the research topic, educa onal material,and nonoriginal studies)
36 Studies met the inclusion criteria 25 Cross-sec onal studies, 7 Qualita ve, 4 both designs.
Analysis and Synthesis Processes Data were presented using descriptive statistics. Quantitative analysis was not possible because of heterogeneity across studies in term of study design, population, setting, and measurement. The research team followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standard (REMSES) guideline in reporting the review.6
Figure 2. Flowchart of search strategy and selection process.
online supplementary Table 3 (available at http://ajmq. sagepub.com/supplemental).
Quality Assessment
Results A total of 36 studies met the inclusion criteria. The majority of the studies (86%) included were published after 2005. The study design was quantitative (cross-sectional surveys) in 25 studies, qualitative design in 7 studies, and both designs in 4 studies. In-depth interviews and focus group discussion were the most common techniques used in the qualitative studies. Figure 2 describes the selection process and the result of the search strategy. A total of 23 studies were conducted in the United States; 2 studies were conducted in each of India, Spain, and Sweden; and the remaining studies were conducted in Asia, Central America, Pakistan, Mauritius, Taiwan, and Turkey. In all, 19 studies evaluated a global measure of perception of quality that reflected longitudinal or comprehensive experience of health care delivery, whereas 17 studies evaluated experience related to a single encounter within the health care system. The study settings ranged from primary/ambulatory care (17 studies), to inpatient care (7 studies), to emergency service (3 studies). The targeted population had chronic diseases in 6 studies and had mental health conditions in 3 studies. Characteristics of the studies included are presented in
Random sampling was used in 33% of the studies, and 42% of the studies used a validated instrument to measure outcomes. Overall, the studies had good response rates (61% of the studies had a respondent rate >50% and 47% of the studies had a response rate >70%); 17% of the studies have unclear response rate reporting. (See online supplementary Table 4, available at http://ajmq.sagepub. com/supplemental.)
Patient Perceptions of Health Care Quality The studies included elicited a wide range of patient perceptions that were described using various terms. A total of 10 main dimensions of health care quality were identified: communication, health care access, shared decision making (SDM), clinical quality/provider knowledge and skills, physical environment, patient education, electronic medical record (EMR), pain control, discharge process, and preventive services. Communication was the most frequent health care quality dimension identified in the included studies, followed by access and SDM. Figure 3 depicts these dimensions and their distribution across the studies.
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Number of studies
25 20 15 10 5 0
Figure 3. Health care quality dimensions identified across the included studies.
Communication. In 26 studies, patients identified the quality of communication as an indicator of high health care quality. Provider–patient communication attributes included the provider’s ability to listen,4 taking the patient seriously and demonstrating respect and courtesy,3,4 clearly explaining a condition and treatment,14,34 language concordance or lack of language barriers,18 a good relationship with providers, increased physician discussion with the patients,30 good patient–physician interactions (improved interpersonal interactions),35 and rapport between doctors and patients.27 Patient-allied health staff communications were similarly described as an indicator of high-quality care and focused on how well patients are treated and whether they are taken seriously by office staff.4 Last, provider–provider communications were described focusing on efficient collaboration between multiple care providers,21,32 interhospital communication, and team collaboration.26 Access. Nineteen studies reported accessibility as an indicator of quality, including appointment accessibility (to primary and specialty care and diagnostic testing)10,14 and provider accessibility, included waiting time to get appointment or to reach the provider, as well as ease of making an appointment and communicating with the provider.12,14,23 Other types of access-related issues were acceptance of multiple payers’ plans/health insurance and geographic accessibility.19,21,26,32 SDM. Nine studies reported SDM as a patient expectation of high-quality care. This included facilitating decision making by patients,10 patient participation in decision making, and responsiveness to patient needs and values.12,26,28
Clinical Quality and Provider’s Knowledge and Skills. Eight studies reported that patients’ perception of quality related directly to how they viewed the clinical quality and provider’s knowledge and skills. This was described by nurses and physicians having a high level of knowledge,8 absence of errors, the treatment causes the patient to feel better,14 the latest technology and drugs are used,14 the thoroughness of the physical examination,3 and frequent staff training.33 Physical Environment. Physical environment of health care facility was cited as a perception of quality in many studies (8 studies). Becker et al examined the effect of physical attractiveness on quality perception and their results support the value of investing in the physical attractiveness of patient areas in the outpatient setting.9 Other physical environment perceptions included comfort of hospital beds,12 cleanliness,24 convenience (high–low examination tables, wide automatic doors, high-contrast signs and lighting, and wheelchairfriendly scales),20 and adequacy of security and parking.16,39 Less Commonly Described Dimensions. Other factors perceived by patients as consistent with high quality are the availability of patient education resources (4 studies),10,12,19 the adequacy and effectiveness of pain control (cited in 4 inpatient and emergency care encounter studies),12,15,34,40 the availability of an EMR and electronic health information exchange (3 studies),7,36 the quality of the hospital discharge process (2 studies),28,37 and the availability of and access to preventive services (2 studies).22,23
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Effect of Setting and Condition Data about patient perceptions of quality based on setting and condition are presented in Table 1. Although the 2012 Survey of US Health Care Consumers41 reports that most patients are accessing primary care either for routine checkups or injury/illness, in the primary care/ambulatory setting, the present study results indicate that provider accessibility is the most commonly reported dimension followed by patient–provider communication and SDM. Provider accessibility perception included a variety of perceptions; availability of health care provider,26 providing different health care services to the patient within the same geographic area,26 patients assigned and attended to by the same providers,23,26 and spending more time caring for patients3 were commonly reported. In the inpatient setting, clinical quality8,33,37 followed by the physical environment were commonly reported. In the emergency department setting, patient–provider communication, followed by physical environment and pain control, were reported. In chronic diseases, patient–provider communication was the most commonly reported perception of quality, followed by provider accessibility and provider–provider communication (Table 1). SDM was most reported in the psychiatric/mental health setting. In 2 studies, the targeted population was exclusively Korean Americans18 and Latinos29; these patients identified patient–provider communication as a key indicator of quality with an emphasis on language barriers.
Geographic Variation Patient–provider communication was the most frequent dimension reported in studies conducted in or outside the United States (n = 12, 9, respectively). The second most frequently reported dimension in the United States was appointment accessibility (10 studies), whereas clinical quality (6 studies) was the second most reported dimension outside the United States. In general, such comparative data were limited (Figure 4).
Discussion The aim of this systematic review was to assess patient perceptions of quality of care. The research team identified 10 quality dimensions from 36 studies. The most common dimensions identified were communication, followed by access, SDM, clinical quality/provider knowledge and skills, and physical environment. It is no surprise that communication—especially patient–provider communication—was cited as the most frequent dimension perceived by patients as important for high-quality health care. Communication was reported as a key quality component across various settings and conditions. A systematic review by Griffin et al42 suggested
that better communication between patients and providers translates into better outcomes. In a qualitative metanarrative review, Waibel et al26 identified interhospital communication and exchange of clinical information between providers as a critical requirement for information and management continuity across care delivery settings. Waibel et al26 also reported similar finding about how patients value SDM, individualized care, and personal involvement in facilitating care. Prior studies43 from the 1970s evaluated patient perception of quality and reported the importance of patients’ beliefs about doctor conduct in terms of quality of care and humaneness of health care delivery. Compared with national surveys, HCAHPS identifies communication with nurses and communication with doctors as the most important domains correlated with overall patient satisfaction. Other domains identified by HCAHPS as important factors correlated with overall patient satisfaction include hospital environment, responsiveness of hospital staff, pain management, communication about medications, and discharge information. Although SDM was identified as a common patient perception of health care, HCAHPS domains do not include SDM.44 The research team identified 8 studies that cited provider’s knowledge, skills, and technical quality as an indicator of good care, particularly in inpatient settings. The results of the present study identified common quality dimensions that health policy makers can take into consideration; access to health care was identified as the second most frequent patient perception cited in the studies reviewed, and appointment and provider accessibility were important for patients perceptions of quality of health care, especially in ambulatory and primary care setting. Although patient experience and perceptions may not be a strong indicator of the quality of clinical care,45 the observed domains valued by patients should be taken into account when clinical processes are designed. It is plausible that addressing the characteristics most important to patients can improve adherence to treatment and follow-up, fidelity to lifestyle and behavioral interventions, and result in patients having more responsibility for and engagement in their care.
Strength and Limitations This study provides a unique view of patient perceptions of health care quality and, to the research team’s knowledge, is the first systematic review to address this question. The team followed an a priori established protocol with preplanned inclusion criteria and an analysis plan. Patient or consumer perception of quality is a construct that is not well defined or standardized, which represents a limitation to this study. In addition, the studies included were heterogeneous, which limited the ability to conduct more
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Table 1. Patient Perceptions of Health Care Quality Subgrouped by Study Setting and Targeted Population Disease. Setting (n) Primary care/Ambulatory care/Not specified (n = 17)
Quality Dimension Patient–provider communication
Provider–provider communication Appointment accessibility
Provider accessibility
Geographic accessibility
Electronic medical record (EMR)
Shared decision making (SDM)
Physical environment
Inpatient (n = 7)
Preventive services Discharge process Clinical quality
Clinical quality
Physical environment
SDM Pain control
Items Described in Studies (n) Good relationship with providers (n = 2) Improve communication with provider (n = 1) Improve patient–physician interactions (improve interpersonal interactions) (n = 2) Patient–provider relationship monitoring (n = 1) Patient treated with respect and courtesy (n = 1) Interhospital communication; exchange of clinical information (n = 1) Less time to get an appointment (n = 1) Satisfaction with appointment waiting time. Waiting time in office (n = 1) Increase access to the doctor whom the patient can trust (n = 1) Assignment to primary provider (n = 1) Availability of a usual physician or nurse when needed (n = 3) Delivered services and providers are at the same location (n = 1) Being attended by the same physician, practice nurse, or small team of physicians (n = 1) Spending more time with patients (n = 1) Responding in a timely manner to patient request (n = 1) Easy access to health care (including access to different level of care) (n = 2) Use of EMRs (n = 1) Presence of electronic HIE (n = 1) Privacy and security of HIE (n = 1) Access to medical records by professionals in different settings (n = 1) Responsiveness to patient needs (n = 2) Adjustment of care to patients’ needs (individualized care) (n = 1) Patients engaging in treatment (n = 1) Adequate preventive health services (n = 1) Receipt of support and preparation for the discharge process (n = 1) Community participation in the design of health care delivery (n = 1) Physician accompanying patient to others settings (n = 1) Thoroughness of routine examination (n = 1) Technical skills, assure accuracy of diagnosis, and provide effective treatment (n = 1) Improve physical attractiveness of the facility (n = 1) Clean, comfortable (no smoking zone), privacy of the patients, familial home-like environment Availability of security and parking (n = 1) Highly knowledgeable and skilled nurse practices (n = 1) High technical and clinical quality of the provider (n = 1) Provide safe health care services (n = 1) In-service training for nurses with special emphasis on communication (n = 1) Comfortable hospital beds (n = 1) Better hospital/ward environment (n = 1) Provide safe health care services (n = 1) Decision participation (n = 2) Adequate pain control, especially in acute setting (n = 1) Effective pain relief (n = 1) (continued)
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Mohammed et al Table 1. (continued) Setting (n)
Quality Dimension
Items Described in Studies (n)
Appointment accessibility Patient education
Discharge process
Chronic Disease (n = 6)
Patient–provider communication
Acceptable waiting time for treatment and examinations (n = 1) Provide information about diagnosis and treatment to the patient (n = 1) Provide adequate patient health education (n = 1) Improve patient stay and discharge process (discharge instruction) (n = 2) Physician’s ability to communicate effectively with patients (n = 1) Promoting measures to improve the relationship among patients and health care providers (n = 1) Good relationship with providers (n = 1) Doctor clearly explains problems and treatments to patient (n = 1) Team helps patients understand their medical conditions (n = 1) Team collaboration among providers (n = 1) Increase appointment time (n = 1) Doctor spends time with patient (n = 1) Specialist doctors available (n = 1) Basic health care available regardless of ability to pay (n = 1) Advanced care available (n = 1) Enhancing physical access (high–low examination tables, wide automatic doors, high-contrast signs and lighting, wheelchair scales) (n = 1) Caring for the patient as an individual (n = 1) Preventive measures: reducing functional decline (n = 1) Doctor is skillful and knowledgeable (n = 1) Errors do not occur (n = 1) Newest technology and drugs are used (n = 1) Effective treatment (n = 1) Build rapport between doctors and patients (n = 1) Being listened to and taken seriously by all staff (GPs, nurses, and receptionists) (n = 1) Being treated with respect, courtesy, and consideration by GPs, nurses, practice managers, and receptionists (n = 1) Alternative talking therapies provided, not just generic counseling (n = 1) Access to services and staff (routine and emergency) when needed (n = 1) Flexible follow-up appointments as required (n = 1) Include patients in decisions (n = 1) Include the client and the family in all phases of treatment (n = 1) Medication education (n = 1) Improve patient–provider communication (n = 3)
Mental Health (n = 3)
Provider–provider communication Appointment accessibility Provider accessibility Geographic accessibility Physical environment SDM Clinical quality
Patient–provider communication
Provider accessibility
Emergency Department (n = 3)
Appointment accessibility SDM
Patient education Patient–provider communication Clinical quality Appointment accessibility Pain control Physical environment Provider–provider communication
High technical performance of providers (physical and emotional recovery) (n = 1) Easy to make an appointment, easy to access by phone (n = 1) Adequate pain management (n = 2) High quality of infrastructure (n = 2) Collaboration between multiple medical care providers (n = 1)
Abbreviations: GP, general practitioner; HIE, health information exchange.
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14
Number of Studies
12 10 8 6 4
USA Other Countries
2 0
Figure 4. Difference in quality dimensions identified in studies conducted in the United States versus other countries.
insightful analysis. Furthermore, nearly 50% of the studies included measured a single patient encounter experience (as opposed to a global measure), which also limits the generalizability of the result. Last, although the research team was able to identify 10 dimensions of patient perceptions of quality, the team was unable to provide the relative importance or weight to enable ranking of these dimensions. This systematic review demonstrated that patients’ perceptions of high-quality care may differ by health care setting and disease condition (eg, communication is potentially more important in outpatient and chronic disease settings, whereas the quality of clinical care and provider expertise more important in inpatient setting); however, these conclusions are based on nonquantitative observations and could be subject to reporting bias.
Conclusion Patients voiced their own opinions and perspectives about quality, which may differ from those of health care providers. The 10 dimensions identified can be used in the planning and evaluation of health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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42. Griffin SJ, Kinmonth AL, Veltman MW, Gillard S, Grant J, Stewart M. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2:595-608. 43. Ware JE Jr, Wright WR, Snyder MK, Chu GC. Consumer perceptions of health care services: implications for academic medicine. J Med Educ. 1975;50:839-848.
44. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48. 45. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359:1921-1931.
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research-article2014
AJMXXX10.1177/1062860614545124American Journal of Medical QualityMohammed et al
Article
Creating a Patient-Centered Health Care Delivery System: A Systematic Review of Health Care Quality From the Patient Perspective
American Journal of Medical Quality 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614545124 ajmq.sagepub.com
Khaled Mohammed, MBBCh, MPH1, Margaret B. Nolan, MD1, Tamim Rajjo, MD2, Nilay D. Shah, PhD1, Larry J. Prokop, MLS1, Prathibha Varkey, MD, MPH3, and Mohammad H. Murad, MD, MPH1
Abstract Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes. Keywords patient perceptions, quality of health care, health care delivery, systematic review, meta-narrative review
Patient experience has gained greater emphasis with the recent introduction of the value-based purchasing (VBP) program implemented by the Centers for Medicare & Medicaid Services. Patient experience is one of the 3 key domains of VBP (the other 2 domains are clinical process of care and outcomes) and accounts for 30% of the total score that determines hospital payment. Similar measures are being developed for physicians and health systems. The focus on patient experience reflects the broader emphasis and movement toward patient-centered care delivery and emphasizes the fact that patients’ care should encompass not only the outcomes of care but also their personal experience of that care. Typically, patient experience is measured using surveys of patient satisfaction after an encounter with the health care system. Patient experience measures can provide robust measures of quality and can capture patient evaluation of care focused on communication with the delivery system.1 Although patient experience surveys have limitations, patient experience data can be used to improve the delivery of health services and patients’ perceptions and experiences with care, and also has the
potential to improve patient outcomes. Furthermore, identifying and improving patient experience of care is a key component of enhancing the value of the health care delivery system for consumers. Although standardized measures of patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are used for performance measurement and payment, prior studies of patient satisfaction have suggested that patients have a complex set of beliefs and expectations about their health care, which may not be represented in traditional patient satisfaction measures.2 Moreover, patients’ assessment of quality is not always aligned with that of providers at the same institution.3 There may be areas of care delivery or 1
Mayo Clinic, Rochester, MN Mercy Family Medicine Residency Program, Toledo, OH 3 Seton Healthcare Family, Austin, TX 2
Corresponding Author: Khaled Mohammed, MBBCh, MPH, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Email: [email protected]
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The quality of health care?
Perceived by health system providers (not within the scope of this analysis)
Perceived by paents
Main Queson: What are paent percepons of high-quality health care? Percepons mapped/converged into discrete dimensions
• • • • • • • • • •
Communicaon Health care access Shared decision making Provider knowledge and skills Physical environment Paent educaon Electronic medical record Pain control Discharge process Prevenve services.
Secondary exploraon: Do dimensions differ by seng/condion/geographic locaon?
and terms. The different terms (here, patient perception of quality) are categorized thematically by independent reviewers. New categories are created until saturation (no new themes are identified). Occasionally, subgroup analysis (inferences based on different settings or populations) can be possible. The methodology and phases of a meta-narrative review are displayed in online supplementary Table 1 (available at http://ajmq.sagepub.com/ supplemental).
Study Eligibility Inclusion Criteria. All studies about patient or consumer perceptions of high-quality health care were included regardless of type of study design (eg, randomized, observational, survey, descriptive, qualitative), population, age, sex, morbidity, or setting (eg, inpatient, outpatient, emergency care). Exclusion Criteria. Nonoriginal, summarized literature, opinions, and educational materials were excluded, as were non-English studies.
Figure 1. Analytic framework.
Literature Search deficiencies in care that may cause dissatisfaction to patients but remain invisible to providers. In addition, there may be a number of other factors, not measured by patient satisfaction or experience, that affect how patients view the quality of a health care system and how they choose where to receive their care. More recently, other modes of capturing patient assessment and experience at individual health care organizations have been developed through common Web sites and applications such as Yelp.4 Therefore, the research team conducted a systematic review of the published literature to better understand the factors that affect patient perceptions of health care organizations. The aims of the study are to explore patient perceptions of quality of health care and to understand how patient perceptions may differ by settings and condition.
A comprehensive search of several databases from 1995 to February 2014 was performed by a reference medical librarian. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Google, and Scirus. Controlled vocabulary and keywords were used to search for terms describing health care quality, health care value, delivery of health care, health care marketing, combined with patient/consumer perceptions, experiences, perspectives, and satisfaction. The search results were visually scanned for relevant articles and Web pages. The detailed search strategy is provided in online supplementary Table 2 (available at http://ajmq.sagepub.com/supplemental).
Methods
To look for the relevant information in sources not published in the biomedical databases, general Internet searches were conducted in duplicate (KM, MN) using Google and Bing. Modified search terms from the biomedical databases search were used. The links were examined until 20 nonrelevant links were identified using saturation and the snowballing approach.
This systematic review was conducted based on the analytic frame work depicted in Figure 1. The meta-narrative approach was followed, as suggested by Greenhalgh et al,5 in which a multidisciplinary team is formed to develop an a priori protocol that includes explicit criteria for study selection and inclusion, plans for data extraction and analysis, and finally to produce inferences or recommendations. This approach is usually followed when the research question is anticipated to be answered by heterogeneous studies that describe different outcome measures
Environmental Scan
Study Selection Two reviewers (KM, MN) independently identified eligible studies by reviewing abstracts and full-text manuscripts.
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Mohammed et al Disagreements between reviewers were reconciled by discussion, consensus, or arbitration by a third reviewer (MHM).
1567 Citations obtained by the search strategy
Quality of Studies Assessment To assess the risk of bias, the research team evaluated adequacy of patient selection, respondent rate, and the use of validated instruments in measuring the targeted outcome.
Data Extraction
1517 Citations excluded by screening titles/abstracts
50 Full-text articles assessed for eligibility
15 Citations obtained by environmental scan
Two reviewers (KM, TR) extracted the data from each study independently. Data extraction forms included the following variables: study population, study setting, study location, study objectives, type of study design, sample size, instruments used in measuring quality perception, patient perception of quality of health care, main finding, and study conclusion.
29 Articles excluded: (No relevance to the research topic, educa onal material,and nonoriginal studies)
36 Studies met the inclusion criteria 25 Cross-sec onal studies, 7 Qualita ve, 4 both designs.
Analysis and Synthesis Processes Data were presented using descriptive statistics. Quantitative analysis was not possible because of heterogeneity across studies in term of study design, population, setting, and measurement. The research team followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standard (REMSES) guideline in reporting the review.6
Figure 2. Flowchart of search strategy and selection process.
online supplementary Table 3 (available at http://ajmq. sagepub.com/supplemental).
Quality Assessment
Results A total of 36 studies met the inclusion criteria. The majority of the studies (86%) included were published after 2005. The study design was quantitative (cross-sectional surveys) in 25 studies, qualitative design in 7 studies, and both designs in 4 studies. In-depth interviews and focus group discussion were the most common techniques used in the qualitative studies. Figure 2 describes the selection process and the result of the search strategy. A total of 23 studies were conducted in the United States; 2 studies were conducted in each of India, Spain, and Sweden; and the remaining studies were conducted in Asia, Central America, Pakistan, Mauritius, Taiwan, and Turkey. In all, 19 studies evaluated a global measure of perception of quality that reflected longitudinal or comprehensive experience of health care delivery, whereas 17 studies evaluated experience related to a single encounter within the health care system. The study settings ranged from primary/ambulatory care (17 studies), to inpatient care (7 studies), to emergency service (3 studies). The targeted population had chronic diseases in 6 studies and had mental health conditions in 3 studies. Characteristics of the studies included are presented in
Random sampling was used in 33% of the studies, and 42% of the studies used a validated instrument to measure outcomes. Overall, the studies had good response rates (61% of the studies had a respondent rate >50% and 47% of the studies had a response rate >70%); 17% of the studies have unclear response rate reporting. (See online supplementary Table 4, available at http://ajmq.sagepub. com/supplemental.)
Patient Perceptions of Health Care Quality The studies included elicited a wide range of patient perceptions that were described using various terms. A total of 10 main dimensions of health care quality were identified: communication, health care access, shared decision making (SDM), clinical quality/provider knowledge and skills, physical environment, patient education, electronic medical record (EMR), pain control, discharge process, and preventive services. Communication was the most frequent health care quality dimension identified in the included studies, followed by access and SDM. Figure 3 depicts these dimensions and their distribution across the studies.
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Number of studies
25 20 15 10 5 0
Figure 3. Health care quality dimensions identified across the included studies.
Communication. In 26 studies, patients identified the quality of communication as an indicator of high health care quality. Provider–patient communication attributes included the provider’s ability to listen,4 taking the patient seriously and demonstrating respect and courtesy,3,4 clearly explaining a condition and treatment,14,34 language concordance or lack of language barriers,18 a good relationship with providers, increased physician discussion with the patients,30 good patient–physician interactions (improved interpersonal interactions),35 and rapport between doctors and patients.27 Patient-allied health staff communications were similarly described as an indicator of high-quality care and focused on how well patients are treated and whether they are taken seriously by office staff.4 Last, provider–provider communications were described focusing on efficient collaboration between multiple care providers,21,32 interhospital communication, and team collaboration.26 Access. Nineteen studies reported accessibility as an indicator of quality, including appointment accessibility (to primary and specialty care and diagnostic testing)10,14 and provider accessibility, included waiting time to get appointment or to reach the provider, as well as ease of making an appointment and communicating with the provider.12,14,23 Other types of access-related issues were acceptance of multiple payers’ plans/health insurance and geographic accessibility.19,21,26,32 SDM. Nine studies reported SDM as a patient expectation of high-quality care. This included facilitating decision making by patients,10 patient participation in decision making, and responsiveness to patient needs and values.12,26,28
Clinical Quality and Provider’s Knowledge and Skills. Eight studies reported that patients’ perception of quality related directly to how they viewed the clinical quality and provider’s knowledge and skills. This was described by nurses and physicians having a high level of knowledge,8 absence of errors, the treatment causes the patient to feel better,14 the latest technology and drugs are used,14 the thoroughness of the physical examination,3 and frequent staff training.33 Physical Environment. Physical environment of health care facility was cited as a perception of quality in many studies (8 studies). Becker et al examined the effect of physical attractiveness on quality perception and their results support the value of investing in the physical attractiveness of patient areas in the outpatient setting.9 Other physical environment perceptions included comfort of hospital beds,12 cleanliness,24 convenience (high–low examination tables, wide automatic doors, high-contrast signs and lighting, and wheelchairfriendly scales),20 and adequacy of security and parking.16,39 Less Commonly Described Dimensions. Other factors perceived by patients as consistent with high quality are the availability of patient education resources (4 studies),10,12,19 the adequacy and effectiveness of pain control (cited in 4 inpatient and emergency care encounter studies),12,15,34,40 the availability of an EMR and electronic health information exchange (3 studies),7,36 the quality of the hospital discharge process (2 studies),28,37 and the availability of and access to preventive services (2 studies).22,23
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Effect of Setting and Condition Data about patient perceptions of quality based on setting and condition are presented in Table 1. Although the 2012 Survey of US Health Care Consumers41 reports that most patients are accessing primary care either for routine checkups or injury/illness, in the primary care/ambulatory setting, the present study results indicate that provider accessibility is the most commonly reported dimension followed by patient–provider communication and SDM. Provider accessibility perception included a variety of perceptions; availability of health care provider,26 providing different health care services to the patient within the same geographic area,26 patients assigned and attended to by the same providers,23,26 and spending more time caring for patients3 were commonly reported. In the inpatient setting, clinical quality8,33,37 followed by the physical environment were commonly reported. In the emergency department setting, patient–provider communication, followed by physical environment and pain control, were reported. In chronic diseases, patient–provider communication was the most commonly reported perception of quality, followed by provider accessibility and provider–provider communication (Table 1). SDM was most reported in the psychiatric/mental health setting. In 2 studies, the targeted population was exclusively Korean Americans18 and Latinos29; these patients identified patient–provider communication as a key indicator of quality with an emphasis on language barriers.
Geographic Variation Patient–provider communication was the most frequent dimension reported in studies conducted in or outside the United States (n = 12, 9, respectively). The second most frequently reported dimension in the United States was appointment accessibility (10 studies), whereas clinical quality (6 studies) was the second most reported dimension outside the United States. In general, such comparative data were limited (Figure 4).
Discussion The aim of this systematic review was to assess patient perceptions of quality of care. The research team identified 10 quality dimensions from 36 studies. The most common dimensions identified were communication, followed by access, SDM, clinical quality/provider knowledge and skills, and physical environment. It is no surprise that communication—especially patient–provider communication—was cited as the most frequent dimension perceived by patients as important for high-quality health care. Communication was reported as a key quality component across various settings and conditions. A systematic review by Griffin et al42 suggested
that better communication between patients and providers translates into better outcomes. In a qualitative metanarrative review, Waibel et al26 identified interhospital communication and exchange of clinical information between providers as a critical requirement for information and management continuity across care delivery settings. Waibel et al26 also reported similar finding about how patients value SDM, individualized care, and personal involvement in facilitating care. Prior studies43 from the 1970s evaluated patient perception of quality and reported the importance of patients’ beliefs about doctor conduct in terms of quality of care and humaneness of health care delivery. Compared with national surveys, HCAHPS identifies communication with nurses and communication with doctors as the most important domains correlated with overall patient satisfaction. Other domains identified by HCAHPS as important factors correlated with overall patient satisfaction include hospital environment, responsiveness of hospital staff, pain management, communication about medications, and discharge information. Although SDM was identified as a common patient perception of health care, HCAHPS domains do not include SDM.44 The research team identified 8 studies that cited provider’s knowledge, skills, and technical quality as an indicator of good care, particularly in inpatient settings. The results of the present study identified common quality dimensions that health policy makers can take into consideration; access to health care was identified as the second most frequent patient perception cited in the studies reviewed, and appointment and provider accessibility were important for patients perceptions of quality of health care, especially in ambulatory and primary care setting. Although patient experience and perceptions may not be a strong indicator of the quality of clinical care,45 the observed domains valued by patients should be taken into account when clinical processes are designed. It is plausible that addressing the characteristics most important to patients can improve adherence to treatment and follow-up, fidelity to lifestyle and behavioral interventions, and result in patients having more responsibility for and engagement in their care.
Strength and Limitations This study provides a unique view of patient perceptions of health care quality and, to the research team’s knowledge, is the first systematic review to address this question. The team followed an a priori established protocol with preplanned inclusion criteria and an analysis plan. Patient or consumer perception of quality is a construct that is not well defined or standardized, which represents a limitation to this study. In addition, the studies included were heterogeneous, which limited the ability to conduct more
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Table 1. Patient Perceptions of Health Care Quality Subgrouped by Study Setting and Targeted Population Disease. Setting (n) Primary care/Ambulatory care/Not specified (n = 17)
Quality Dimension Patient–provider communication
Provider–provider communication Appointment accessibility
Provider accessibility
Geographic accessibility
Electronic medical record (EMR)
Shared decision making (SDM)
Physical environment
Inpatient (n = 7)
Preventive services Discharge process Clinical quality
Clinical quality
Physical environment
SDM Pain control
Items Described in Studies (n) Good relationship with providers (n = 2) Improve communication with provider (n = 1) Improve patient–physician interactions (improve interpersonal interactions) (n = 2) Patient–provider relationship monitoring (n = 1) Patient treated with respect and courtesy (n = 1) Interhospital communication; exchange of clinical information (n = 1) Less time to get an appointment (n = 1) Satisfaction with appointment waiting time. Waiting time in office (n = 1) Increase access to the doctor whom the patient can trust (n = 1) Assignment to primary provider (n = 1) Availability of a usual physician or nurse when needed (n = 3) Delivered services and providers are at the same location (n = 1) Being attended by the same physician, practice nurse, or small team of physicians (n = 1) Spending more time with patients (n = 1) Responding in a timely manner to patient request (n = 1) Easy access to health care (including access to different level of care) (n = 2) Use of EMRs (n = 1) Presence of electronic HIE (n = 1) Privacy and security of HIE (n = 1) Access to medical records by professionals in different settings (n = 1) Responsiveness to patient needs (n = 2) Adjustment of care to patients’ needs (individualized care) (n = 1) Patients engaging in treatment (n = 1) Adequate preventive health services (n = 1) Receipt of support and preparation for the discharge process (n = 1) Community participation in the design of health care delivery (n = 1) Physician accompanying patient to others settings (n = 1) Thoroughness of routine examination (n = 1) Technical skills, assure accuracy of diagnosis, and provide effective treatment (n = 1) Improve physical attractiveness of the facility (n = 1) Clean, comfortable (no smoking zone), privacy of the patients, familial home-like environment Availability of security and parking (n = 1) Highly knowledgeable and skilled nurse practices (n = 1) High technical and clinical quality of the provider (n = 1) Provide safe health care services (n = 1) In-service training for nurses with special emphasis on communication (n = 1) Comfortable hospital beds (n = 1) Better hospital/ward environment (n = 1) Provide safe health care services (n = 1) Decision participation (n = 2) Adequate pain control, especially in acute setting (n = 1) Effective pain relief (n = 1) (continued)
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Mohammed et al Table 1. (continued) Setting (n)
Quality Dimension
Items Described in Studies (n)
Appointment accessibility Patient education
Discharge process
Chronic Disease (n = 6)
Patient–provider communication
Acceptable waiting time for treatment and examinations (n = 1) Provide information about diagnosis and treatment to the patient (n = 1) Provide adequate patient health education (n = 1) Improve patient stay and discharge process (discharge instruction) (n = 2) Physician’s ability to communicate effectively with patients (n = 1) Promoting measures to improve the relationship among patients and health care providers (n = 1) Good relationship with providers (n = 1) Doctor clearly explains problems and treatments to patient (n = 1) Team helps patients understand their medical conditions (n = 1) Team collaboration among providers (n = 1) Increase appointment time (n = 1) Doctor spends time with patient (n = 1) Specialist doctors available (n = 1) Basic health care available regardless of ability to pay (n = 1) Advanced care available (n = 1) Enhancing physical access (high–low examination tables, wide automatic doors, high-contrast signs and lighting, wheelchair scales) (n = 1) Caring for the patient as an individual (n = 1) Preventive measures: reducing functional decline (n = 1) Doctor is skillful and knowledgeable (n = 1) Errors do not occur (n = 1) Newest technology and drugs are used (n = 1) Effective treatment (n = 1) Build rapport between doctors and patients (n = 1) Being listened to and taken seriously by all staff (GPs, nurses, and receptionists) (n = 1) Being treated with respect, courtesy, and consideration by GPs, nurses, practice managers, and receptionists (n = 1) Alternative talking therapies provided, not just generic counseling (n = 1) Access to services and staff (routine and emergency) when needed (n = 1) Flexible follow-up appointments as required (n = 1) Include patients in decisions (n = 1) Include the client and the family in all phases of treatment (n = 1) Medication education (n = 1) Improve patient–provider communication (n = 3)
Mental Health (n = 3)
Provider–provider communication Appointment accessibility Provider accessibility Geographic accessibility Physical environment SDM Clinical quality
Patient–provider communication
Provider accessibility
Emergency Department (n = 3)
Appointment accessibility SDM
Patient education Patient–provider communication Clinical quality Appointment accessibility Pain control Physical environment Provider–provider communication
High technical performance of providers (physical and emotional recovery) (n = 1) Easy to make an appointment, easy to access by phone (n = 1) Adequate pain management (n = 2) High quality of infrastructure (n = 2) Collaboration between multiple medical care providers (n = 1)
Abbreviations: GP, general practitioner; HIE, health information exchange.
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14
Number of Studies
12 10 8 6 4
USA Other Countries
2 0
Figure 4. Difference in quality dimensions identified in studies conducted in the United States versus other countries.
insightful analysis. Furthermore, nearly 50% of the studies included measured a single patient encounter experience (as opposed to a global measure), which also limits the generalizability of the result. Last, although the research team was able to identify 10 dimensions of patient perceptions of quality, the team was unable to provide the relative importance or weight to enable ranking of these dimensions. This systematic review demonstrated that patients’ perceptions of high-quality care may differ by health care setting and disease condition (eg, communication is potentially more important in outpatient and chronic disease settings, whereas the quality of clinical care and provider expertise more important in inpatient setting); however, these conclusions are based on nonquantitative observations and could be subject to reporting bias.
Conclusion Patients voiced their own opinions and perspectives about quality, which may differ from those of health care providers. The 10 dimensions identified can be used in the planning and evaluation of health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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