HEALTH CONSUMERS CSIRO PUBLISHING
Australian Health Review, 2015, 39, 109–116 http://dx.doi.org/10.1071/AH14079
Experiencing health care service quality: through patients’ eyes Sharon Schembri PhD (Uni Qld), BBUS (Hons I) College of Business Administration, University of Texas–Pan American, 1201 West University Drive, Edinburg, TX 78541, USA. Email: [email protected]
Abstract Objective. The primary aim of the present study was to consider health care service quality from the patients’ perspective, specifically through the patient’s eyes. Method. A narrative analysis was performed on 300 patient stories. This rigorous analysis of patient stories is designed to identify and describe health care service quality through patients’ eyes in an authentic and accurate, experiential manner. Results. The findings show that there are variant and complex ways that patients experience health care service quality. Conclusion. Patient stories offer an authentic view of the complex ways that patients experience health care service quality. Narrative analysis is a useful tool to identify and describe how patients experience health care service quality. Patients experience health care service quality in complex and varying ways. What is known about the topic? Patient satisfaction measures are increasingly used for benchmark and accreditation purposes. Measures of patient satisfaction are considered indicative measures of service quality and quality of care. However, the measurement of patient satisfaction and service quality is not an accurate reflection of what and how patients experience health care. What does this paper add? This paper takes a narrative approach and analyses 300 patient stories to demonstrate the essence of patients’ evaluation of health care service quality. What are the implications for practitioners? Health care service quality is shown to be experienced in various ways. Identifying and describing these different ways of experiencing health care service quality provides practitioners with strategic insight into improving the quality of service they provide outside the realm of objective satisfaction measures. These findings also demonstrate the value in a third-party feedback system. Additional keywords: narrative analysis, patient experience, patient opinion, patient satisfaction. Received 12 March 2014, accepted 21 August 2014, published online 16 October 2014
Introduction The question of quality is a complex phenomenon that is compounded in the context of healthcare.1 In the past three decades, there has been a shift in healthcare towards a patient-centred model of care.2 This shift towards a patient-centred model has instigated the requirement to take into account the patients’ perspective.3,4 Consequently, measures of patient satisfaction5,6 and service quality7 have been formulated and implemented, and even required within general practice medicine accreditation processes,8 for example. However, although the importance and significance of the patient perspective is increasingly recognised within healthcare practice, the argument put forward in this paper is that measuring patient satisfaction and service quality does not provide an accurate depiction of the patients’ perspective. The aim of this research is to demonstrate there is depth and complexity in the patients’ perspective that is not captured in measuring patient satisfaction and/or service quality. More than striving to satisfy patients, the quest to enhance the patients’ Journal compilation Ó AHHA 2015
experience of health care service must aim to capture and manage this suggested complexity. To this end, this research presents a narrative analysis of unsolicited health care stories about experiences within the Australian healthcare system. To begin this narrative analysis of health care stories, this paper presents a brief review of patient satisfaction and service quality literature. The argument developed is that the measures of patient satisfaction and service quality are not an accurate reflection of patient experience. From there, the narrative methodology is explained, where a diverse sample of health care stories from a variety of healthcare settings, including acute care and general practice, is used to demonstrate the experiential meaning of health care. The findings reported here demonstrate the lived experience of health care service quality and the inherent complexity in the patients’ experience of health care service quality. In a practical sense, therefore, this work is relevant to health care service providers by way of moving closer to a genuine patientcentred approach. www.publish.csiro.au/journals/ahr
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Patient satisfaction and service quality measurement The focus on patient satisfaction in healthcare is driven by the quest to measure and improve the quality of service.6,9,10 From a traditional functionalist perspective, patients lack the expert knowledge to assess the technical competence of medical personnel accurately.11 Research is yet to identify how healthcare consumers make service quality assessments.12–17 The patient’s physical or emotional state may further hinder accurate judgment.17 Patients are also influenced by proxies such as the interpersonal skills of front-line personnel, raising the issue of a good bedside manner masking questionable technical quality, for example. Some argue, therefore, that patients are not customers18,19 and that satisfied patients are not considered necessary in providing a quality service.12 Shifting to a patient-centred approach has stimulated further need to investigate, document and measure the perceptions of patients.20,21 This emphasis on evaluating the patients’ subjective views is increasingly operationalised by measuring satisfaction.5–7,17 However, conceptualisations of service quality and customer satisfaction are inadequate in accommodating the complexities involved between health care providers and patients for several reasons.22 Research specifically addressing the inadequacy of patient satisfaction, the lack of rigour in patient satisfaction measures and the lack of focus on patient experience is well recognised.6,12,13,16 Another consideration is the reluctance on the part of the patient to critique medical professionals, given their status and authority.23 The broad application of patient satisfaction measurement within health care services reports a generally satisfied community of patients,12,24 with specific studies reporting up to 96.5% patient satisfaction.25 The lack of variation in this measurement is just one aspect that has led professionals to question the validity of such a measurement.12,26 Several health care researchers present further evidence to suggest that the objective measurement of patient satisfaction is an imperfect means for measuring highly subjective phenomena associated with quality assessment.13–16 Nevertheless, satisfaction has gained widespread recognition as an appropriate measure of quality in the context of healthcare.12,27,28 As well, healthcare policy in some countries (e.g. the UK) attributes partial income according to patient surveys as per the national quality and outcomes framework.29 According to the American College of Healthcare Executives, if patients are highly satisfied with care in the broadest sense, then the most manageable part of the hospital’s mission is accomplished.30 In Australia and New Zealand, measurement of patient satisfaction is an integral component of the general practice medicine accreditation process.27 To serve that purpose, specialist organisations have emerged that are dedicated to the task where the generic push suggests that measurement of patient satisfaction can deliver improved patient outcomes, improved staff morale, enhanced organisational reputation and better bottom line economics. However, there are several factors that potentially limit the validity of satisfaction as an indicator of quality.12,17,26 More than that, patient satisfaction as an indicator of quality is argued to be seriously flawed and perceived service quality is advocated as a superior approach to quality management within healthcare services.5,7
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There are several service quality models that have been widely applied31 with the SERVQUAL instrument noted as dominant.7 Recognising SERVQUAL as a widely accepted and applied instrument, a meta-analysis of 30 SERVQUAL applications highlights some theoretical and empirical concerns.32 Review of service quality applications in medicinal services and specifically plastic surgery services indicates that a dissection of medical service quality into functional quality and technical quality measurements may be frutiful.33,34 More broadly, this dissection of service quality into functional (process) quality and technical (outcome) quality is advocated by other service quality researchers.34–40 Historically, therefore, the medical profession has focussed on technical aspects of medical service provision.1–3 In contrast, consumers typically focus on functional aspects as a proxy in evaluating the quality of the medical service received.22,37 In other words, functional quality assessment is used by consumers to judge the service overall; in contrast, medical professionals focus on technical quality. Indeed, one of the critiques of SERVQUAL is that there is an overemphasis on process.32,33,39 Accordingly, with a focus on process rather than outcome, SERVQUAL measures perceived quality not objective quality.36 Therefore, an emphasis on the social reality of patient experience is required.10,16 Patients’ experience Patients’ experience of health care services is becoming increasingly central to assessing the performance of healthcare systems.20,21,29 The medical profession is now commonly judging quality of care by not only measuring clinical quality and safety, but also by gathering the views of patients.41–43 This information is valuable in terms of monitoring the performance of healthcare organisations, for informing patient choice and for informing policy development.43–45 However, investigating patient experience is beyond quantitative measurement of patient satisfaction or health care service quality.10,16 Measures of patient satisfaction and healthcare service quality are predefined measures that do not include an experiential perspective: the lived experience of health care services, in other words. To understand the experiential meaning of healthcare, the investigative process begins with the patient stories or health care narratives rather than any predefined measures of satisfaction or quality. An in-depth narrative analysis of patient experience can provide a detailed understanding of the meaning(s) individuals hold in the evaluation of health care service quality.16,42 Similarly, the ‘what’ (or transactional and technical) aspects along with the ‘how’ (or relational and functional) aspects of the health care service both have meaning for the patient.46–48 By considering the patients’ experience of health care service quality as the point of reference, the experiential meaning of health care service quality is demonstrated to vary according to what and how the patient understands the constitution of quality.16,42 The usefulness of patient stories therefore lies in the ability to vividly communicate the layered depth and complexity of health care service experiences. Methods Narrative analysis is well demonstrated as a useful analytical tool in the study of the subjective experience of health and illness.46–48
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As a well established methodology, narrative analysis is used as a method to show how people manage the ambiguity and disruptions involved with the experience of illness.46,49 This research project employed narrative analysis50,51 to a collection of more than 300 unsolicited stories of health care service experiences. This collection of unsolicited stories was drawn from publicly available information published by www.patientopinion.org.au (accessed 19 May 2013). Patient Opinion is an independent organisation that posts unsolicited stories about experiences within the Australian healthcare system. Established in 2012 and reflecting the UK Patient Opinion founded in 2005, the Australian organisation operates on the premise that meaningful conversations between patients and health care service providers are key to achieving quality services. Contributions are welcomed from throughout the community and organisations choose to subscribe for a small fee, which enables a feedback loop between the community and service providers. In Australia, more than 50 healthcare organisations currently subscribe to Patient Opinion. With privacy as a priority, incoming stories are moderated to ensure anonymity for contributors. Negative stories are posted as anonymous and only first names are published if the story is positive. Clinicians are also not identified so as to maintain the safety of the site. As well, Patient Opinion gives incoming stories a critical score and the health care service provider is contacted before publication if the criticality of the story is rated high. This step allows providers to respond before the story and the response being published. At the point of writing, Patient Opinion had received more than 300 patient stories with over 120 000 viewings. As unsolicited stories, these stories have not been initiated by the researcher, nor have they been generated as the result of interviews. These stories are narratives voluntarily offered by community members; accordingly, the story tellers have an open invitation to share the good, the bad and the ugly. One of the advantages of this approach is the nominal interactional pressure compared with standard research interview situations. The 300 unsolicited stories depict a variety of healthcare settings and a non-specific group of contributors. From this sample of stories, the purpose of the narrative analysis was to identify and describe the patients’ experience of health care service quality. To begin the analytical process, the stories were considered structurally in terms of what the basic elements of the narrative were and how the patient experienced these service elements apparent in the narrative. This analytical process is in line with phenomenological principles52–54 where the person and the world are assumed to be inherently related via the individual’s lived experience. Analysing healthcare experiences in terms of what is part of the story and how that part of the story is enacted enables a contextual view of the aspects of the healthcare experience being reported.15 Some stories had a positive forefront and a less prominent negative background; conversely, some stories had a negative foreground with a less prominent positive background. In analysing the text in this way, rather than using deliberate and defined5 coding techniques,55 contextual meaning and specifically experiential meaning were the analytical priorities.15,16 For this reason, analytical software was not used, given the stated focus on contextual and experiential meaning rather than pre-defined codes.
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Results The initial process of narrative analysis identified 217 positive stories and 179 negative stories where the prominent aspect of the story was the analytical focus. Although many stories were only a few lines long, others were quite detailed and lengthy, extending over several pages. Notably, some stories comprised both positive and negative aspects, as shown in Table 1 for Story #1 and #2. This demonstrated complexity within the patient experience of health care services is recognised as gestaltism.6,56 Double-sided stories such as Stories #1 and #2 were included in both the positive and negative thematic counts. Story #1 is a story about a birthing experience that praised the medical and health professionals involved for the autonomy she was afforded and the attentive care she received. This positive foreground of the story is, however, contrasted with the negative background of the story. Beyond the positive birthing experience in the foreground, the story involved aspects related to postnatal depression, patient mix in the ward, breastfeeding and infant medications. These various aspects demonstrate the holistic nature of health care service experience. From this broader holistic and experiential perspective, the healthcare experience described encompasses a breadth of issues beyond the birth aspect alone. Similarly, in Story #2, the patient describes the years of back and neck pain treatment received from various practitioners, which is a functional description. More holistically, the lived experience of the treatment provided maintenance but not effective treatment. This negative foreground of the story is contrasted with a positive background of the story, where the patient describes how she returned to the practitioner who listened and sought to understand the condition. Beyond the initial dissection of positive experience and negative experience, the stories were continuously sorted and resorted to arrive at stability in groupings. Aiming for further depth of analysis, emergent themes were identified as three positive and three negative, where the positive themes mirrored the negative themes, which are considered reflective of process, outcome and time. In the positive themes, stories related to process were identified and described as attentive and considerate service stories, and experience related to outcome were identified and described as effective treatment stories. Similarly, in the negative themes, stories related to process were identified and described as ongoing problem stories and stories related to outcome were identified and described as service failure stories. The third emergent theme for both positive and negative stories was time-related. The following discussion details each of these six emergent themes. In detailing each of these six themes, some stories are shown to include aspects related to more than one distinct theme. In this way, the experiential meaning of health care service quality is shown to be highly complex, where positive stories include, for example, aspects of attentive and considerate service (process-related) as well as effective treatment (outcomerelated) and timely service aspects (time-related). Similarly, some negative stories include aspects of ongoing problems (process related) as well as service failure (outcome related) and/or slow and unresponsive service aspects (time related). Positive stories Positive patient stories ranged from process stories about attentive and considerate service (n = 126) to outcome-related stories about
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Table 1. Patient stories MW, midwife; C-section; Caesarian section; PND, postnatal depression; GP, general practitioner; RBWH, Royal Brisbane and Women’s Hospital; ED, emergency department; IV, intravenous Story #
Evident theme
Illustrative quote
1
Positive foreground; negative background
Giving birth at the Mater Hospital, Sydney 14 months ago I gave birth to my son via C-section at the Mater Hospital, Sydney. I can honestly not say enough good things about my experience. All the MWs, nurses and doctors I saw were amazing. I wanted to pretty much be left alone and that was what they did – checking on me occasionally to make sure all was fine. While I was there, another mum came back to the ward with PND, becoming psychotic over the next 24 h. I was in the room next to her and it was very scary listening to her pain at 3 : 00 a.m. in the morning, especially as a new mum with a newborn. When I went to talk to the staff in tears, they were wonderful. Found another room for me for the night; made sure I was OK. I do think there can still be more education around breastfeeding with some staff. In my opinion, it is not good to shove a baby on a mum’s boob. I think there should be more education around a gentle parenting approach, teaching mums to follow their instincts. I also believe that in the classes I did after birth that we should discuss what you should do when your baby gets a temperature for the first time. How to handle it rather than medicating straight away.
2
Negative foreground; positive background
Ongoing back and neck pain After years of physiotherapists, osteopaths, acupuncture, massage therapists and Nurofen, I asked my doctor to refer me to a [musculoskeletal] specialist. I thought there must be an answer to the ongoing pain and discomfort, and hoped a specialist practitioner could help. The treatment involved more anti-inflammatory medication and anaesthetic injections into the local area of pain. I thought I would be in for a more specialist or proactive treatment and consequently did not return. I didn’t feel inclined to pursue this situation with my GP in case he was offended at the feedback aimed at his colleague. So back to massage and physio and stretches and exercises, thanks to the excellent help from my local physio, who seems to listen well and ask the right questions and can always put his hand on the exact location of the pain or injury just by ‘listening’ to me complain. I guess the moral of my story is I will always return to the listener as the first alternative rather than risk prescription of more drugs and then counter drugs for damage control.
3
Positive: attentive and considerate service (process related)
Awesome postnatal follow up (Women’s and Children’s, Adelaide) After having two children in private hospitals, we chose Adelaide Women’s and Children’s Hospital for our third, as we specifically wanted a water birth. Not only did we have great support in that but the follow-up care was incredibly good. We had a home visit on Days 1, 3 and 5, and then were offered more in-home MW care but didn’t need it. Instead, the hospital followed up with a phone call and a referral to family and youth health for ongoing care. We felt so well supported and confident with the excellent care and attention to detail.
4
Positive: effective treatment (outcome related)
Praise for RBWH staff: hand vs broken wine glass I have nothing but praise for the staff I saw at the RBWH. A few months ago, I was on the losing end of an encounter with a broken wine glass. I was seen promptly and given 10 stitches by an ED resident. The scar is barely noticeable and I cannot thank the staff I saw enough for looking after me. I believe we are very lucky to have the public health care system that we do!
5
Positive: time (time related)
The care and service I was given was excellent (Horsham Hospital) I had to go to Horsham casualty to have test done. I was referred by another doctor. I was there for at least 7 hours and saw they were very busy. There was a male nurse who attended to me the whole time I was there, and the care and service I was given was excellent. In my experience, it is not too often I got that kind of care.
6
Positive: combination of considerate and attentive service as well as timely and effective treatment
Great GP at the Kaamunda Surgery, WA I got an appointment with a GP I didn’t know at the practice I usually go to, on a day when I was due to fly overseas. He was quite good and I saw him again. He seems to listen as though I am the only patient for the day, shows genuine concern about my symptoms and has provided excellent short- and long-term care for a chronic disease I have. What a gem!
7
Negative: ongoing problems (process related)
No information on how my treatment fits with my ability to work I have been given no real information about how my treatment fits in with my ability to work. There are a lot of times when I don’t feel well and if I do any work (even cleaning up), I will sleep for 3–4 h after. This isn’t me. Antidepressants don’t appear to improve things for me but pain meds do. I have been diagnosed with chronic pain syndrome and I think the problem may be the cyst. I have been waiting for 5 years to get my cyst fixed. From what I have read, epidemiological studies point to raised deep vein pressure as causing all kinds of vein damage. I can get no real answer to getting back to being (continued next page)
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Table 1. (continued ) Story #
Evident theme
Illustrative quote productive. I don’t blame the Charters Towers Hospital, as I believe they are dangerously underresourced and, in the present climate, there may be little they can do. From what I have experienced, there seem to be procedural problems, which indicate to me that some people are working to an impossible schedule. Maybe I will have a pulmonary embolism and expire before they need to do anything.
8
Negative: service failure (outcome related)
My tubes were tied against my wishes and without consent I had a planned C-section in 2011 and had decided not to have my tubes tied, and withdrew consent. The doctor who performed my surgery made me feel so small and insignificant and, in my opinion, went so far as to insult me because I had changed my mind. I found out not quite a year later that my tubes were tied. As to how they were tied or clamped or cut, no one seems to know. The only reason I found out was because of the excruciating pain I was in when I ovulated. I now suffer insomnia, irregular incredibly heavy periods, ovary pain, acne, intense itching, constipation and mood swings, and cannot have any more children. I was 28 when this happened. I tried to complain; I felt it was all ignored. I asked whether or not my tubes had been tied; that was denied. I’m scarred for life because of one doctor. One doctor who, I believe, had absolutely no right to do what they did.
9
Negative: time issues (time related)
Waiting time at Mater Public Emergency Wife fell and knocked herself out in the middle of the night and starting convulsing. Once she came round, took her to Mater Public emergency at around 1 : 00 a.m. It took 1.5 h before we actually got a bed and someone examined her. They then said they will have to do a scan before they release her. Seven hours later, scan was done; 3 h later, finally released. That is just not good enough! I think if it had been serious after 10 h, she could have been dead.
10
Negative: combination of service failure, ongoing problems and time issues
An awful ordeal for my teenage son at Canberra Hospital Recently, I took my son to the emergency dept at the Canberra Hospital, and he was seen promptly and diagnosed with appendicitis. He was in a lot of pain and given strong pain killers. We were told he needed surgery. Thirteen hours later, we were informed that he had been ‘bumped’ and [was] not having his operation, as there was no theatre and staff available due to other priorities. I was very angry and upset for my son. The next morning, I expected he would be first, as he had been delayed already but we were told they hoped to do it today but no promises due to other priorities. I was taught appendicitis was an emergency! [At] 4 : 00 p.m. that day, he was moved to day surgery and eventually, at 8: 30 p.m., he went for his operation. On removal of the appendix, it perforated so now he would need 2–7 days of IV antibiotics. He remained in day surgery. Two days after his operation, he was in lots of pain, [with] an extended abdomen and now a temperature of 398C. I asked for an ultrasound, as I suspected pus in his abdominal cavity. I was ignored but, eventually, they agreed to do the next morning. It showed fluid and pus, so my poor son had to go back to theatre for a second operation to clear out the fluid and pus, and had a drain put in for 2 days. He was moved to a ward after the second operation to find he had to share with a female patient, which I feel was totally unacceptable. I feel very strongly about the fact that if the operation had not been delayed, he would not have had complications. In the long run, it has cost the hospital more money; by not opening another theatre, my son had two operations and 9 days in hospital.
effective treatment (n = 72) and time-related stories about timely service (n = 19). Illustrative quotes for each of these three themes are presented in Table 1 as Stories #3–6. Process-related positive stories about attentive and considerate services included many instances of quality health care. Story #3 is reflective of these myriad stories about attentive and considerate service. In this story, the patient describes feeling ‘so well supported and confident with the excellent care’. This positive experience is reinforced at several levels of the health care service; from interaction with the midwife to the other hospital personnel, and corresponding follow-up care and referrals. Outcome-related positive stories about effective treatment also included many examples of quality health care. Story #4 is reflective of the many stories about effective treatment. In this story, the patient praises the hospital staff and health system, noting a barely noticeable scar. Time-related positive stories were also many and varied, with Story #5 capturing the essence of that
theme. This story entails a 7-h casualty wait where the service is described as excellent. Story #6 is a more complex story that combines aspects of attentive and considerate service, as well as effective treatment and timely service. Story #6 illustrates the patient experience as encompassing the service system of a general practice clinic, where prompt and effective service scheduling is combined with considerate and attentive service from the doctor, given that the treatment effectively manages a chronic condition. Story #6 presents an experience that encompasses process and outcome as well as time, thus demonstrating the multidimensional complexity of the patients’ experience of health care service quality. Negative stories Negative patient stories ranged from process stories about service failure (n = 44) to outcome-related stories about ongoing
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problems (n = 122) and time-related stories about slow and unresponsive service (n = 13). Illustrative quotes for each of these three themes are presented in Table 1 as Stories #7–10. Process-related negative stories about ongoing problems included many stories of disturbing health care experiences. Story #7 tells the story of a discouraged worker who hoped for an embolism and expiration as potential relief. This negativity continues with outcome-related stories about service failure. Service failure stories included many instances where the system failed the patient, with some stories being more consequential than others. Story #8, for example, depicts a situation of fertility sterilisation occurring without the patient’s consent. Consequently, the patient now faces various debilitating challenges, as well as the prospect of having no more children at the age of 28. This serious service failure is described by the patient in terms of poor doctor–patient interaction, where the doctor performing the surgery made the patient feel ‘small and insignificant’ and even insulted. Other serious service failure stories included the story of a woman with a broken elbow that was misdiagnosed as a dislocation and plastered at a 908 angle. As she tells it, ‘12 months later, numerous [occupational therapy] sessions and major out of pocket expenses, I still can’t fully straighten my elbow and, according to the orthopaedic surgeon, most likely never will.’ Service failures in healthcare often compound underlying issues and yet the patient is left to cope regardless. The point of health care service quality is that this is a matter of life and death. Story #9 is told by the husband whose wife hit her head and was convulsing. On arrival at the emergency ward, they waited 1.5 h for an examination, then another 7 hours for a scan and 3 hours more before release. Time or, more specifically, a lack of response, also compounded the service issues as experienced by the patient. Story #10 illustrates a case of service failure combined with non-responsiveness compounding the negative experience and generation of ongoing problems. Discussion Narrative analysis of patient stories has enabled a perspective of the experience of health care services through the patient’s eyes. This analysis shows that stories about health care as experienced by the patient can be both positive and negative in either foreground or background. This evidence of gestaltism is specifically illustrated with Stories #1 and 2 presented Table 1. Story #1 shows a positive foreground contrasted with a negative background. Similarly, but in reverse order, Story #2 shows a negative foreground with a positive background. The complexity is also demonstrated in that patient stories about health care experiences are not confined to one dimension but include aspects related to process, outcome and time, for example. Considering health care from the perspective of patient experience highlights the complexity of issues as seen through the patient’s eyes. Although the findings presented here may seem logical or unsurprising, the evidence demonstrates that health care service evaluation entails more than the simplicity of being satisfied or not and beyond a single encounter with one practitioner or professional. With this in mind, health care service providers seeking to take into account the patient perspective in an authentic manner must consider the service experience both experientially and holistically. Measurement of patient satisfaction is therefore not advised as an authentic
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and accurate depiction of what and how patients experience. Pragmatic action taken as a consequence of patient satisfaction measures may even be offtrack. The quest to provide quality health care services and enhance the patient experience of healthcare must aim to capture and manage this identified complexity. The evidence confirms that the patient does indeed feel the service, as shown specifically with Stories #3, 6, 7 and 10. Nevertheless, traditional functionalists suggest patients may not have the competence to assess the technical quality of medical care.13,26 The findings show, however, that patients are expressively clear when effective treatment is received or not, as seen in Stories #4, 6 and 8. In these stories, the storyteller is acutely aware of when technical competence has or has not been part of the experience. Certainly, Story #8, depicting lack of consent, provides strong support for the suggestion that patients can and do indeed evaluate technical competence. This narrative evidence therefore suggests that while patients may feel the service, the evidence does not support the suggested patient ineptitude in evaluating technical competence. Indeed, practitioners would do well to co-opt the insight and knowledge of patients who experience their service to comprehend more fully where improvements can be made. This research is an initial step to that end as well as a methodological demonstration as to how service providers might begin the task. However, the advantage of unsolicited stories received through a third-party organisation is the protection of privacy for all concerned and the integrity of the text. Further research could be conducted to investigate the underlying motivations of such online contributions. The findings as summarised in Table 1 also indicate that patients are not focussed on satisfaction but are rather more concerned about service standards. Experience of a system in crisis has many compounding factors, as evident in Story #7 and her forgiving sentiment that the people working in the system are stretched beyond what resources are available. Unmistakably, however, service failures in healthcare can escalate to matters of life and death. More specifically, and highly evident in these findings, patients are assessing not only the functional quality of the service they experience but also the technical quality of the service they experience. Time is also shown to be a prioritised evaluative dimension of the patient experience of health care service. This finding is in line with current research,15,43 which demonstrates that the experiential meaning of health care service quality varies in terms of how patients understand the question of (healthcare) quality, but with the added time dimension. Conclusion The question of quality is a complex phenomenon that is compounded in the context of healthcare. However, the point of health care service quality can be a matter of life and death. Narrative analysis of patient stories has enabled an insightful description of the patients’ experience of health care services. The evidence presented in this paper shows there is complexity and layered depth to the patients’ perspective that is not captured in measuring patient satisfaction. The findings presented here show that narrative analysis is a useful approach to capture and potentially manage the complexities of how patients experience health care service. By looking at the evaluation of health care services from the fundamental perspective of the patient experience, this work
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has demonstrated that both functional and technical aspects of healthcare each hold meaning for the patient, but with the added evaluative dimension of time. To conclude, this research shows the value of considering health care service quality through patients’ eyes. Competing interests None declared. Acknowledgement The author would like to acknowledge Alexandra Espinoza and her efforts as research assistant on this project. Thank you Alexandra.
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18 Mulhall K, Ahmed A, Masterson E. The ‘doctor–customer’ relationship: Hippocrates in the modern marketplace. Int J Health Care Qual Assur 2002; 15: 9–10. doi:10.1108/09526860210415551 19 Nair BR. Patient, client or customer? Med J Aust 1998; 169: 593–7. 20 Grøndahl VA, Karlsson I, Hall-Lord ML, Appelgren J, Wilde-Larsson B. Quality of care from patients’ perspective: impact of the combination of person-related and external objective care conditions. J Clin Nurs 2011; 20: 2540–51. doi:10.1111/j.1365-2702.2011.03810.x 21 Grøndahl VA, Wilde-Larsson B, Karlsson I, Hall-Lord ML. Patients’ experiences of care quality and satisfaction during hospital stay: a qualitative study. Eur J Person Centered Healthcare 2013; 1: 185–92. doi:10.5750/ejpch.v1i1.650 22 Lengnick-Hall CA. The patient as a pivot point for quality in health care delivery. Hosp Health Serv Adm 1995; 40: 25–39. 23 Roter D, Hall J. Doctors talking with patients/patients talking with doctors: improving communication in medical visits. Westport, CT: Auburn House; 1992. 24 Williams SJ, Calnan M. Key determinants of consumer satisfaction with general practice. Fam Pract 1991; 8: 237–42. doi:10.1093/fampra/ 8.3.237 25 Dougall A, Russell A, Rubin G, Ling J. Rethinking patient satisfaction: patient experiences of an open access flexible simoidoscopy service. Soc Sci Med 2000; 50: 53–62. doi:10.1016/S0277-9536(99)00256-7 26 Vuori H. Patient satisfaction: does it matter? Qual Assur Health Care 1991; 3: 183–9. doi:10.1093/intqhc/3.3.183 27 Greco M, Sweeney K, Brownlea A, McGovern J. The practice accreditation and improvement survey (PAIS): what patients think. Aust Fam Physician 2001; 30: 1096–100. 28 Taylor SA. Distinguishing service quality from patient satisfaction in developing health care marketing strategies. Hosp Health Serv Adm 1994; 39: 221–36. 29 Salisbury C, Wallace M, Montgomery AA. Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling. BMJ 2010; 341: c5004. 30 American College of Healthcare Executives (ACHE). Beyond the silver bullet: ensuring patient and employee satisfaction. Chicago: ACHE; 2006. Available at: https://www.ache.org/seminars/seminar.cfm? PC=CRSVC [verified 11 March 2014]. 31 Seth N, Deshmukh SG, Vrat P. Service quality models: a review. Int J Qual Reliab Manage 2005; 22: 913–49. doi:10.1108/026567105106 25211 32 Ladhari R. A review of twenty years of SERVQUAL research. Int J Qual Serv Sci 2009; 1: 172–98. doi:10.1108/17566690910971445 33 Fiala TG. What do patients want? Technical quality versus functional quality. Aesthet Surg J 2012; 32: 751–9. doi:10.1177/1090820X12 452555 34 Rashid WEW, Jusoff HK. Service quality in health care setting. Int J Health Care Qual Assur 2009; 22: 471–82. doi:10.1108/095268609 10975580 35 Grönroos C. A service quality model and its marketing implications. Eur J Mark 1984; 18: 36–44. doi:10.1108/EUM0000000004784 36 Asubonteng P, McCleary KJ, Swan JE. SERVQUAL revisited: a critical review of service quality. J Serv Mark 1996; 10: 62–81. doi:10.1108/ 08876049610148602 37 Babakus E, Mangold WG. Adapting the SERVQUAL scale to hospital services: an empirical investigation. Health Serv Res 1992; 26: 767–86. 38 Parasuraman A, Zeithaml V, Berry L. Reassessment of expectations as a comparison standard in measuring service quality: implications for future research. J Mark 1994; 58: 111–24. doi:10.2307/1252255 39 Parasuraman A, Zeithaml V, Berry L. Refinement and reassessment of the SERVQUAL scale. J Retailing 1991; 67: 420–50. 40 Parasuraman A, Zeithaml V, Berry L. SERVQUAL: a multiple-item scale for measuring consumer perceptions of service quality. J Retailing 1988; 64: 12–39.
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41 Greaves F, Ramirez-Cano D, Millett C, Darzi A, Donaldson L. Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Qual Saf 2013; 22: 251–255. doi:10.1136/ bmjqs-2012-001527 42 Greaves F, Pape UJ, King D, Darzi A, Majeed A, Wachter RM, Millett C. Associations between internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study. BMJ Qual Saf 2012; 21: 600–605. doi:10.1136/bmjqs-2012-000906 43 Merkouris A, Papathanassoglou ED, Lemonidou C. Evaluation of patient satisfaction with nursing care: quantitative or qualitative approach? Int J Nurs Stud 2004; 41: 355–67. doi:10.1016/j.ijnurstu.2003. 10.006 44 Mpinga EK, Chastonay P. Satisfaction of patients: a right to health indicator? Health Policy 2011; 100: 144–50. doi:10.1016/j.healthpol. 2010.11.001 45 Tsianakas V, Maben J, Wiseman T, Robe G, Richardson A, Madden P, Griffin M, Davies EA. Using patients’ experiences to identify priorities for quality improvement in breast cancer care: patient narratives, surveys or both? BMC Health Serv Res 2012; 12: 271. doi:10.1186/1472-696312-271 46 Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988.
47 Polkinghorne DE. Narrative knowing and the human sciences. Albany, NY: Suny Press; 1988. 48 Frank AW. The wounded storyteller: body, illness, and ethics. Chicago: University of Chicago Press; 2013. 49 Becker G. Disrupted lives: how people create meaning in a chaotic world. Berkeley, CA: University of California Press; 1997. 50 Riessman CK. Narrative analysis. Vol 30. Newbury Park, CA: Sage; 1993. 51 Riessman CK. Narrative analysis. In: Huberman M, Miles MB, editors. The qualitative researcher’s companion. Thousand Oaks, CA: Sage; 2002. pp. 217–70. 52 Macquarrie J, Robinson E (Transl). Being and Time by M Heidegger. New York: Harper; 1962. 53 Husserl E. The crisis of European sciences and transcendental phenomenology: an introduction to phenomenological philosophy. Evaston, IL: Northwestern University Press; 1970. 54 Smith C (Transl.) Phenomenology of perception by M Merleau-Ponty. London: Routledge; 1962. 55 Strauss AL. Qualitative analysis for social scientists. New York: Cambridge University Press, 1987. 56 Koffka K. Principles of gestalt psychology. London: Lund Humphries; 1935.
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 109–116 http://dx.doi.org/10.1071/AH14079
Experiencing health care service quality: through patients’ eyes Sharon Schembri PhD (Uni Qld), BBUS (Hons I) College of Business Administration, University of Texas–Pan American, 1201 West University Drive, Edinburg, TX 78541, USA. Email: [email protected]
Abstract Objective. The primary aim of the present study was to consider health care service quality from the patients’ perspective, specifically through the patient’s eyes. Method. A narrative analysis was performed on 300 patient stories. This rigorous analysis of patient stories is designed to identify and describe health care service quality through patients’ eyes in an authentic and accurate, experiential manner. Results. The findings show that there are variant and complex ways that patients experience health care service quality. Conclusion. Patient stories offer an authentic view of the complex ways that patients experience health care service quality. Narrative analysis is a useful tool to identify and describe how patients experience health care service quality. Patients experience health care service quality in complex and varying ways. What is known about the topic? Patient satisfaction measures are increasingly used for benchmark and accreditation purposes. Measures of patient satisfaction are considered indicative measures of service quality and quality of care. However, the measurement of patient satisfaction and service quality is not an accurate reflection of what and how patients experience health care. What does this paper add? This paper takes a narrative approach and analyses 300 patient stories to demonstrate the essence of patients’ evaluation of health care service quality. What are the implications for practitioners? Health care service quality is shown to be experienced in various ways. Identifying and describing these different ways of experiencing health care service quality provides practitioners with strategic insight into improving the quality of service they provide outside the realm of objective satisfaction measures. These findings also demonstrate the value in a third-party feedback system. Additional keywords: narrative analysis, patient experience, patient opinion, patient satisfaction. Received 12 March 2014, accepted 21 August 2014, published online 16 October 2014
Introduction The question of quality is a complex phenomenon that is compounded in the context of healthcare.1 In the past three decades, there has been a shift in healthcare towards a patient-centred model of care.2 This shift towards a patient-centred model has instigated the requirement to take into account the patients’ perspective.3,4 Consequently, measures of patient satisfaction5,6 and service quality7 have been formulated and implemented, and even required within general practice medicine accreditation processes,8 for example. However, although the importance and significance of the patient perspective is increasingly recognised within healthcare practice, the argument put forward in this paper is that measuring patient satisfaction and service quality does not provide an accurate depiction of the patients’ perspective. The aim of this research is to demonstrate there is depth and complexity in the patients’ perspective that is not captured in measuring patient satisfaction and/or service quality. More than striving to satisfy patients, the quest to enhance the patients’ Journal compilation Ó AHHA 2015
experience of health care service must aim to capture and manage this suggested complexity. To this end, this research presents a narrative analysis of unsolicited health care stories about experiences within the Australian healthcare system. To begin this narrative analysis of health care stories, this paper presents a brief review of patient satisfaction and service quality literature. The argument developed is that the measures of patient satisfaction and service quality are not an accurate reflection of patient experience. From there, the narrative methodology is explained, where a diverse sample of health care stories from a variety of healthcare settings, including acute care and general practice, is used to demonstrate the experiential meaning of health care. The findings reported here demonstrate the lived experience of health care service quality and the inherent complexity in the patients’ experience of health care service quality. In a practical sense, therefore, this work is relevant to health care service providers by way of moving closer to a genuine patientcentred approach. www.publish.csiro.au/journals/ahr
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Patient satisfaction and service quality measurement The focus on patient satisfaction in healthcare is driven by the quest to measure and improve the quality of service.6,9,10 From a traditional functionalist perspective, patients lack the expert knowledge to assess the technical competence of medical personnel accurately.11 Research is yet to identify how healthcare consumers make service quality assessments.12–17 The patient’s physical or emotional state may further hinder accurate judgment.17 Patients are also influenced by proxies such as the interpersonal skills of front-line personnel, raising the issue of a good bedside manner masking questionable technical quality, for example. Some argue, therefore, that patients are not customers18,19 and that satisfied patients are not considered necessary in providing a quality service.12 Shifting to a patient-centred approach has stimulated further need to investigate, document and measure the perceptions of patients.20,21 This emphasis on evaluating the patients’ subjective views is increasingly operationalised by measuring satisfaction.5–7,17 However, conceptualisations of service quality and customer satisfaction are inadequate in accommodating the complexities involved between health care providers and patients for several reasons.22 Research specifically addressing the inadequacy of patient satisfaction, the lack of rigour in patient satisfaction measures and the lack of focus on patient experience is well recognised.6,12,13,16 Another consideration is the reluctance on the part of the patient to critique medical professionals, given their status and authority.23 The broad application of patient satisfaction measurement within health care services reports a generally satisfied community of patients,12,24 with specific studies reporting up to 96.5% patient satisfaction.25 The lack of variation in this measurement is just one aspect that has led professionals to question the validity of such a measurement.12,26 Several health care researchers present further evidence to suggest that the objective measurement of patient satisfaction is an imperfect means for measuring highly subjective phenomena associated with quality assessment.13–16 Nevertheless, satisfaction has gained widespread recognition as an appropriate measure of quality in the context of healthcare.12,27,28 As well, healthcare policy in some countries (e.g. the UK) attributes partial income according to patient surveys as per the national quality and outcomes framework.29 According to the American College of Healthcare Executives, if patients are highly satisfied with care in the broadest sense, then the most manageable part of the hospital’s mission is accomplished.30 In Australia and New Zealand, measurement of patient satisfaction is an integral component of the general practice medicine accreditation process.27 To serve that purpose, specialist organisations have emerged that are dedicated to the task where the generic push suggests that measurement of patient satisfaction can deliver improved patient outcomes, improved staff morale, enhanced organisational reputation and better bottom line economics. However, there are several factors that potentially limit the validity of satisfaction as an indicator of quality.12,17,26 More than that, patient satisfaction as an indicator of quality is argued to be seriously flawed and perceived service quality is advocated as a superior approach to quality management within healthcare services.5,7
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There are several service quality models that have been widely applied31 with the SERVQUAL instrument noted as dominant.7 Recognising SERVQUAL as a widely accepted and applied instrument, a meta-analysis of 30 SERVQUAL applications highlights some theoretical and empirical concerns.32 Review of service quality applications in medicinal services and specifically plastic surgery services indicates that a dissection of medical service quality into functional quality and technical quality measurements may be frutiful.33,34 More broadly, this dissection of service quality into functional (process) quality and technical (outcome) quality is advocated by other service quality researchers.34–40 Historically, therefore, the medical profession has focussed on technical aspects of medical service provision.1–3 In contrast, consumers typically focus on functional aspects as a proxy in evaluating the quality of the medical service received.22,37 In other words, functional quality assessment is used by consumers to judge the service overall; in contrast, medical professionals focus on technical quality. Indeed, one of the critiques of SERVQUAL is that there is an overemphasis on process.32,33,39 Accordingly, with a focus on process rather than outcome, SERVQUAL measures perceived quality not objective quality.36 Therefore, an emphasis on the social reality of patient experience is required.10,16 Patients’ experience Patients’ experience of health care services is becoming increasingly central to assessing the performance of healthcare systems.20,21,29 The medical profession is now commonly judging quality of care by not only measuring clinical quality and safety, but also by gathering the views of patients.41–43 This information is valuable in terms of monitoring the performance of healthcare organisations, for informing patient choice and for informing policy development.43–45 However, investigating patient experience is beyond quantitative measurement of patient satisfaction or health care service quality.10,16 Measures of patient satisfaction and healthcare service quality are predefined measures that do not include an experiential perspective: the lived experience of health care services, in other words. To understand the experiential meaning of healthcare, the investigative process begins with the patient stories or health care narratives rather than any predefined measures of satisfaction or quality. An in-depth narrative analysis of patient experience can provide a detailed understanding of the meaning(s) individuals hold in the evaluation of health care service quality.16,42 Similarly, the ‘what’ (or transactional and technical) aspects along with the ‘how’ (or relational and functional) aspects of the health care service both have meaning for the patient.46–48 By considering the patients’ experience of health care service quality as the point of reference, the experiential meaning of health care service quality is demonstrated to vary according to what and how the patient understands the constitution of quality.16,42 The usefulness of patient stories therefore lies in the ability to vividly communicate the layered depth and complexity of health care service experiences. Methods Narrative analysis is well demonstrated as a useful analytical tool in the study of the subjective experience of health and illness.46–48
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As a well established methodology, narrative analysis is used as a method to show how people manage the ambiguity and disruptions involved with the experience of illness.46,49 This research project employed narrative analysis50,51 to a collection of more than 300 unsolicited stories of health care service experiences. This collection of unsolicited stories was drawn from publicly available information published by www.patientopinion.org.au (accessed 19 May 2013). Patient Opinion is an independent organisation that posts unsolicited stories about experiences within the Australian healthcare system. Established in 2012 and reflecting the UK Patient Opinion founded in 2005, the Australian organisation operates on the premise that meaningful conversations between patients and health care service providers are key to achieving quality services. Contributions are welcomed from throughout the community and organisations choose to subscribe for a small fee, which enables a feedback loop between the community and service providers. In Australia, more than 50 healthcare organisations currently subscribe to Patient Opinion. With privacy as a priority, incoming stories are moderated to ensure anonymity for contributors. Negative stories are posted as anonymous and only first names are published if the story is positive. Clinicians are also not identified so as to maintain the safety of the site. As well, Patient Opinion gives incoming stories a critical score and the health care service provider is contacted before publication if the criticality of the story is rated high. This step allows providers to respond before the story and the response being published. At the point of writing, Patient Opinion had received more than 300 patient stories with over 120 000 viewings. As unsolicited stories, these stories have not been initiated by the researcher, nor have they been generated as the result of interviews. These stories are narratives voluntarily offered by community members; accordingly, the story tellers have an open invitation to share the good, the bad and the ugly. One of the advantages of this approach is the nominal interactional pressure compared with standard research interview situations. The 300 unsolicited stories depict a variety of healthcare settings and a non-specific group of contributors. From this sample of stories, the purpose of the narrative analysis was to identify and describe the patients’ experience of health care service quality. To begin the analytical process, the stories were considered structurally in terms of what the basic elements of the narrative were and how the patient experienced these service elements apparent in the narrative. This analytical process is in line with phenomenological principles52–54 where the person and the world are assumed to be inherently related via the individual’s lived experience. Analysing healthcare experiences in terms of what is part of the story and how that part of the story is enacted enables a contextual view of the aspects of the healthcare experience being reported.15 Some stories had a positive forefront and a less prominent negative background; conversely, some stories had a negative foreground with a less prominent positive background. In analysing the text in this way, rather than using deliberate and defined5 coding techniques,55 contextual meaning and specifically experiential meaning were the analytical priorities.15,16 For this reason, analytical software was not used, given the stated focus on contextual and experiential meaning rather than pre-defined codes.
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Results The initial process of narrative analysis identified 217 positive stories and 179 negative stories where the prominent aspect of the story was the analytical focus. Although many stories were only a few lines long, others were quite detailed and lengthy, extending over several pages. Notably, some stories comprised both positive and negative aspects, as shown in Table 1 for Story #1 and #2. This demonstrated complexity within the patient experience of health care services is recognised as gestaltism.6,56 Double-sided stories such as Stories #1 and #2 were included in both the positive and negative thematic counts. Story #1 is a story about a birthing experience that praised the medical and health professionals involved for the autonomy she was afforded and the attentive care she received. This positive foreground of the story is, however, contrasted with the negative background of the story. Beyond the positive birthing experience in the foreground, the story involved aspects related to postnatal depression, patient mix in the ward, breastfeeding and infant medications. These various aspects demonstrate the holistic nature of health care service experience. From this broader holistic and experiential perspective, the healthcare experience described encompasses a breadth of issues beyond the birth aspect alone. Similarly, in Story #2, the patient describes the years of back and neck pain treatment received from various practitioners, which is a functional description. More holistically, the lived experience of the treatment provided maintenance but not effective treatment. This negative foreground of the story is contrasted with a positive background of the story, where the patient describes how she returned to the practitioner who listened and sought to understand the condition. Beyond the initial dissection of positive experience and negative experience, the stories were continuously sorted and resorted to arrive at stability in groupings. Aiming for further depth of analysis, emergent themes were identified as three positive and three negative, where the positive themes mirrored the negative themes, which are considered reflective of process, outcome and time. In the positive themes, stories related to process were identified and described as attentive and considerate service stories, and experience related to outcome were identified and described as effective treatment stories. Similarly, in the negative themes, stories related to process were identified and described as ongoing problem stories and stories related to outcome were identified and described as service failure stories. The third emergent theme for both positive and negative stories was time-related. The following discussion details each of these six emergent themes. In detailing each of these six themes, some stories are shown to include aspects related to more than one distinct theme. In this way, the experiential meaning of health care service quality is shown to be highly complex, where positive stories include, for example, aspects of attentive and considerate service (process-related) as well as effective treatment (outcomerelated) and timely service aspects (time-related). Similarly, some negative stories include aspects of ongoing problems (process related) as well as service failure (outcome related) and/or slow and unresponsive service aspects (time related). Positive stories Positive patient stories ranged from process stories about attentive and considerate service (n = 126) to outcome-related stories about
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Table 1. Patient stories MW, midwife; C-section; Caesarian section; PND, postnatal depression; GP, general practitioner; RBWH, Royal Brisbane and Women’s Hospital; ED, emergency department; IV, intravenous Story #
Evident theme
Illustrative quote
1
Positive foreground; negative background
Giving birth at the Mater Hospital, Sydney 14 months ago I gave birth to my son via C-section at the Mater Hospital, Sydney. I can honestly not say enough good things about my experience. All the MWs, nurses and doctors I saw were amazing. I wanted to pretty much be left alone and that was what they did – checking on me occasionally to make sure all was fine. While I was there, another mum came back to the ward with PND, becoming psychotic over the next 24 h. I was in the room next to her and it was very scary listening to her pain at 3 : 00 a.m. in the morning, especially as a new mum with a newborn. When I went to talk to the staff in tears, they were wonderful. Found another room for me for the night; made sure I was OK. I do think there can still be more education around breastfeeding with some staff. In my opinion, it is not good to shove a baby on a mum’s boob. I think there should be more education around a gentle parenting approach, teaching mums to follow their instincts. I also believe that in the classes I did after birth that we should discuss what you should do when your baby gets a temperature for the first time. How to handle it rather than medicating straight away.
2
Negative foreground; positive background
Ongoing back and neck pain After years of physiotherapists, osteopaths, acupuncture, massage therapists and Nurofen, I asked my doctor to refer me to a [musculoskeletal] specialist. I thought there must be an answer to the ongoing pain and discomfort, and hoped a specialist practitioner could help. The treatment involved more anti-inflammatory medication and anaesthetic injections into the local area of pain. I thought I would be in for a more specialist or proactive treatment and consequently did not return. I didn’t feel inclined to pursue this situation with my GP in case he was offended at the feedback aimed at his colleague. So back to massage and physio and stretches and exercises, thanks to the excellent help from my local physio, who seems to listen well and ask the right questions and can always put his hand on the exact location of the pain or injury just by ‘listening’ to me complain. I guess the moral of my story is I will always return to the listener as the first alternative rather than risk prescription of more drugs and then counter drugs for damage control.
3
Positive: attentive and considerate service (process related)
Awesome postnatal follow up (Women’s and Children’s, Adelaide) After having two children in private hospitals, we chose Adelaide Women’s and Children’s Hospital for our third, as we specifically wanted a water birth. Not only did we have great support in that but the follow-up care was incredibly good. We had a home visit on Days 1, 3 and 5, and then were offered more in-home MW care but didn’t need it. Instead, the hospital followed up with a phone call and a referral to family and youth health for ongoing care. We felt so well supported and confident with the excellent care and attention to detail.
4
Positive: effective treatment (outcome related)
Praise for RBWH staff: hand vs broken wine glass I have nothing but praise for the staff I saw at the RBWH. A few months ago, I was on the losing end of an encounter with a broken wine glass. I was seen promptly and given 10 stitches by an ED resident. The scar is barely noticeable and I cannot thank the staff I saw enough for looking after me. I believe we are very lucky to have the public health care system that we do!
5
Positive: time (time related)
The care and service I was given was excellent (Horsham Hospital) I had to go to Horsham casualty to have test done. I was referred by another doctor. I was there for at least 7 hours and saw they were very busy. There was a male nurse who attended to me the whole time I was there, and the care and service I was given was excellent. In my experience, it is not too often I got that kind of care.
6
Positive: combination of considerate and attentive service as well as timely and effective treatment
Great GP at the Kaamunda Surgery, WA I got an appointment with a GP I didn’t know at the practice I usually go to, on a day when I was due to fly overseas. He was quite good and I saw him again. He seems to listen as though I am the only patient for the day, shows genuine concern about my symptoms and has provided excellent short- and long-term care for a chronic disease I have. What a gem!
7
Negative: ongoing problems (process related)
No information on how my treatment fits with my ability to work I have been given no real information about how my treatment fits in with my ability to work. There are a lot of times when I don’t feel well and if I do any work (even cleaning up), I will sleep for 3–4 h after. This isn’t me. Antidepressants don’t appear to improve things for me but pain meds do. I have been diagnosed with chronic pain syndrome and I think the problem may be the cyst. I have been waiting for 5 years to get my cyst fixed. From what I have read, epidemiological studies point to raised deep vein pressure as causing all kinds of vein damage. I can get no real answer to getting back to being (continued next page)
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Table 1. (continued ) Story #
Evident theme
Illustrative quote productive. I don’t blame the Charters Towers Hospital, as I believe they are dangerously underresourced and, in the present climate, there may be little they can do. From what I have experienced, there seem to be procedural problems, which indicate to me that some people are working to an impossible schedule. Maybe I will have a pulmonary embolism and expire before they need to do anything.
8
Negative: service failure (outcome related)
My tubes were tied against my wishes and without consent I had a planned C-section in 2011 and had decided not to have my tubes tied, and withdrew consent. The doctor who performed my surgery made me feel so small and insignificant and, in my opinion, went so far as to insult me because I had changed my mind. I found out not quite a year later that my tubes were tied. As to how they were tied or clamped or cut, no one seems to know. The only reason I found out was because of the excruciating pain I was in when I ovulated. I now suffer insomnia, irregular incredibly heavy periods, ovary pain, acne, intense itching, constipation and mood swings, and cannot have any more children. I was 28 when this happened. I tried to complain; I felt it was all ignored. I asked whether or not my tubes had been tied; that was denied. I’m scarred for life because of one doctor. One doctor who, I believe, had absolutely no right to do what they did.
9
Negative: time issues (time related)
Waiting time at Mater Public Emergency Wife fell and knocked herself out in the middle of the night and starting convulsing. Once she came round, took her to Mater Public emergency at around 1 : 00 a.m. It took 1.5 h before we actually got a bed and someone examined her. They then said they will have to do a scan before they release her. Seven hours later, scan was done; 3 h later, finally released. That is just not good enough! I think if it had been serious after 10 h, she could have been dead.
10
Negative: combination of service failure, ongoing problems and time issues
An awful ordeal for my teenage son at Canberra Hospital Recently, I took my son to the emergency dept at the Canberra Hospital, and he was seen promptly and diagnosed with appendicitis. He was in a lot of pain and given strong pain killers. We were told he needed surgery. Thirteen hours later, we were informed that he had been ‘bumped’ and [was] not having his operation, as there was no theatre and staff available due to other priorities. I was very angry and upset for my son. The next morning, I expected he would be first, as he had been delayed already but we were told they hoped to do it today but no promises due to other priorities. I was taught appendicitis was an emergency! [At] 4 : 00 p.m. that day, he was moved to day surgery and eventually, at 8: 30 p.m., he went for his operation. On removal of the appendix, it perforated so now he would need 2–7 days of IV antibiotics. He remained in day surgery. Two days after his operation, he was in lots of pain, [with] an extended abdomen and now a temperature of 398C. I asked for an ultrasound, as I suspected pus in his abdominal cavity. I was ignored but, eventually, they agreed to do the next morning. It showed fluid and pus, so my poor son had to go back to theatre for a second operation to clear out the fluid and pus, and had a drain put in for 2 days. He was moved to a ward after the second operation to find he had to share with a female patient, which I feel was totally unacceptable. I feel very strongly about the fact that if the operation had not been delayed, he would not have had complications. In the long run, it has cost the hospital more money; by not opening another theatre, my son had two operations and 9 days in hospital.
effective treatment (n = 72) and time-related stories about timely service (n = 19). Illustrative quotes for each of these three themes are presented in Table 1 as Stories #3–6. Process-related positive stories about attentive and considerate services included many instances of quality health care. Story #3 is reflective of these myriad stories about attentive and considerate service. In this story, the patient describes feeling ‘so well supported and confident with the excellent care’. This positive experience is reinforced at several levels of the health care service; from interaction with the midwife to the other hospital personnel, and corresponding follow-up care and referrals. Outcome-related positive stories about effective treatment also included many examples of quality health care. Story #4 is reflective of the many stories about effective treatment. In this story, the patient praises the hospital staff and health system, noting a barely noticeable scar. Time-related positive stories were also many and varied, with Story #5 capturing the essence of that
theme. This story entails a 7-h casualty wait where the service is described as excellent. Story #6 is a more complex story that combines aspects of attentive and considerate service, as well as effective treatment and timely service. Story #6 illustrates the patient experience as encompassing the service system of a general practice clinic, where prompt and effective service scheduling is combined with considerate and attentive service from the doctor, given that the treatment effectively manages a chronic condition. Story #6 presents an experience that encompasses process and outcome as well as time, thus demonstrating the multidimensional complexity of the patients’ experience of health care service quality. Negative stories Negative patient stories ranged from process stories about service failure (n = 44) to outcome-related stories about ongoing
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problems (n = 122) and time-related stories about slow and unresponsive service (n = 13). Illustrative quotes for each of these three themes are presented in Table 1 as Stories #7–10. Process-related negative stories about ongoing problems included many stories of disturbing health care experiences. Story #7 tells the story of a discouraged worker who hoped for an embolism and expiration as potential relief. This negativity continues with outcome-related stories about service failure. Service failure stories included many instances where the system failed the patient, with some stories being more consequential than others. Story #8, for example, depicts a situation of fertility sterilisation occurring without the patient’s consent. Consequently, the patient now faces various debilitating challenges, as well as the prospect of having no more children at the age of 28. This serious service failure is described by the patient in terms of poor doctor–patient interaction, where the doctor performing the surgery made the patient feel ‘small and insignificant’ and even insulted. Other serious service failure stories included the story of a woman with a broken elbow that was misdiagnosed as a dislocation and plastered at a 908 angle. As she tells it, ‘12 months later, numerous [occupational therapy] sessions and major out of pocket expenses, I still can’t fully straighten my elbow and, according to the orthopaedic surgeon, most likely never will.’ Service failures in healthcare often compound underlying issues and yet the patient is left to cope regardless. The point of health care service quality is that this is a matter of life and death. Story #9 is told by the husband whose wife hit her head and was convulsing. On arrival at the emergency ward, they waited 1.5 h for an examination, then another 7 hours for a scan and 3 hours more before release. Time or, more specifically, a lack of response, also compounded the service issues as experienced by the patient. Story #10 illustrates a case of service failure combined with non-responsiveness compounding the negative experience and generation of ongoing problems. Discussion Narrative analysis of patient stories has enabled a perspective of the experience of health care services through the patient’s eyes. This analysis shows that stories about health care as experienced by the patient can be both positive and negative in either foreground or background. This evidence of gestaltism is specifically illustrated with Stories #1 and 2 presented Table 1. Story #1 shows a positive foreground contrasted with a negative background. Similarly, but in reverse order, Story #2 shows a negative foreground with a positive background. The complexity is also demonstrated in that patient stories about health care experiences are not confined to one dimension but include aspects related to process, outcome and time, for example. Considering health care from the perspective of patient experience highlights the complexity of issues as seen through the patient’s eyes. Although the findings presented here may seem logical or unsurprising, the evidence demonstrates that health care service evaluation entails more than the simplicity of being satisfied or not and beyond a single encounter with one practitioner or professional. With this in mind, health care service providers seeking to take into account the patient perspective in an authentic manner must consider the service experience both experientially and holistically. Measurement of patient satisfaction is therefore not advised as an authentic
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and accurate depiction of what and how patients experience. Pragmatic action taken as a consequence of patient satisfaction measures may even be offtrack. The quest to provide quality health care services and enhance the patient experience of healthcare must aim to capture and manage this identified complexity. The evidence confirms that the patient does indeed feel the service, as shown specifically with Stories #3, 6, 7 and 10. Nevertheless, traditional functionalists suggest patients may not have the competence to assess the technical quality of medical care.13,26 The findings show, however, that patients are expressively clear when effective treatment is received or not, as seen in Stories #4, 6 and 8. In these stories, the storyteller is acutely aware of when technical competence has or has not been part of the experience. Certainly, Story #8, depicting lack of consent, provides strong support for the suggestion that patients can and do indeed evaluate technical competence. This narrative evidence therefore suggests that while patients may feel the service, the evidence does not support the suggested patient ineptitude in evaluating technical competence. Indeed, practitioners would do well to co-opt the insight and knowledge of patients who experience their service to comprehend more fully where improvements can be made. This research is an initial step to that end as well as a methodological demonstration as to how service providers might begin the task. However, the advantage of unsolicited stories received through a third-party organisation is the protection of privacy for all concerned and the integrity of the text. Further research could be conducted to investigate the underlying motivations of such online contributions. The findings as summarised in Table 1 also indicate that patients are not focussed on satisfaction but are rather more concerned about service standards. Experience of a system in crisis has many compounding factors, as evident in Story #7 and her forgiving sentiment that the people working in the system are stretched beyond what resources are available. Unmistakably, however, service failures in healthcare can escalate to matters of life and death. More specifically, and highly evident in these findings, patients are assessing not only the functional quality of the service they experience but also the technical quality of the service they experience. Time is also shown to be a prioritised evaluative dimension of the patient experience of health care service. This finding is in line with current research,15,43 which demonstrates that the experiential meaning of health care service quality varies in terms of how patients understand the question of (healthcare) quality, but with the added time dimension. Conclusion The question of quality is a complex phenomenon that is compounded in the context of healthcare. However, the point of health care service quality can be a matter of life and death. Narrative analysis of patient stories has enabled an insightful description of the patients’ experience of health care services. The evidence presented in this paper shows there is complexity and layered depth to the patients’ perspective that is not captured in measuring patient satisfaction. The findings presented here show that narrative analysis is a useful approach to capture and potentially manage the complexities of how patients experience health care service. By looking at the evaluation of health care services from the fundamental perspective of the patient experience, this work
Experiencing health care service quality
has demonstrated that both functional and technical aspects of healthcare each hold meaning for the patient, but with the added evaluative dimension of time. To conclude, this research shows the value of considering health care service quality through patients’ eyes. Competing interests None declared. Acknowledgement The author would like to acknowledge Alexandra Espinoza and her efforts as research assistant on this project. Thank you Alexandra.
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