CHAPTER 8:DISCUSSION FROM THE QUALITATIVE STUDY
8.2 Discussion of Themes
8.2.1 Theme 1: The Experience of Care as an Indicator for Evaluating the Quality of Health Service
Sub Theme: The Experience of Care as a Measure for Quality and Quality Improvement When the patient provides feedback on patient experience, it enables the NSM to have a better understanding of the processes that work and those that do not. Hence the feedback enables the management team to ascertain if the quality of health delivery is at the required standard. The respondents also indicate that the feedback on patient experience measures enables the NSM to identify areas that need to be positively reformed and the systems that need to be redesigned to support the provision of quality health care. Hence the feedback allows for the management team
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to develop and implement QI programs and initiatives that can improve the quality of service delivery and support positive reform. There is an evident understanding and appreciation of the role of patient experience as a measurement tool.
According to the National Institute for Health and Clinical Excellence (2012:10) the role of patient satisfaction in evaluating quality has been minimised. According to Needham (2015:255) the degree of satisfaction is inadequate to drive positive change for the experience of care.
Researchers are of the belief that the inconsistencies related to patient's background and health conditions cannot be adequately investigated with satisfaction rating question (Fenton et al.,2012:1678). There is therefore a gap that has been identified specifically within the healthcare context. The move away from patient satisfaction is in agreement with the Care Quality Commission (2011:10). An example of this is seen in UK's National Health System (NHS) where a patient experience survey is used in the evaluation of service delivery and patient experience. As a consequence, the survey data of patient experience is providing insight into areas of healthcare that require focused improvement and positive reform. According to IOM there is a general agreement that in developed countries patient experience within the health care context is a "practically, managerially, and clinically important concept to measure" (IOM, 2001:32). The majority of the respondents' viewpoints are in keeping with the viewpoint offered by the Beryl Institute (2014:15) and the IOM where the measurement of patient experience is important and relevant in the current healthcare environment. The findings of the present study which highlight the benefits of measuring patient experience are in agreement with the benefits cited by the Beryl Institute's which are as follows (Beryl Institute,2015:16):
• "identify gaps in service;
• to gain insights into issues that contribute towards negative effects on patient care; and,
• To innovate and/or redesign processes in order to better deliver care with patients".
Whilst the benefits are clear, there still exists an opposition to the use of patient experience data.
Patients may have a tendency to provide feedback that may not be reliable or credible and the uses of audits that are performed by the DoH provide a more reliable form of feedback.
However, upon delving further into the DoH audit process, it is noted that the patient is excluded from participation in the audit process. Therefore the feedback is based primarily on officials that are from the DoH who perform an evaluation of the clinic based on predetermined criteria
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(PSC,2010:19). This type of scenario can present an opportunity for poor service delivery to go unnoticed especially when promotions and performance reviews of healthcare professionals are at stake. In addition the problem of colluding among healthcare staff at the clinic and the official inspectors may hinder the process of inspection and work against the objectives of the National Health Inspection Authorities in SA.
This viewpoints offered, where the concept of measuring patient experience is counterproductive, is in agreement with the findings of Manary et al. who supported the notion that patient feedback is not credible. However, the reasons cited for the lack of credibility in the Manary et al. study were attributed to the fact that patients lacked formal medical training and the understanding that the actual patient experience could be potentially influenced by factors outside of the health service process (Manary et al.,2013:368). Whilst it is probable that the patient’s experience can be potentially influenced by external variables that do not necessarily encompass the health experience, De Silva (2013:198) explains that measuring patient experience is beneficial in both the clinical and business case. De Silva further suggested the need for greater support in the collection and use of patient experience data especially in developing countries.
The Batho Pele Principle of Customer Impact which clearly outlines the need for evaluating the benefits that have been provided for customers both internally and externally states as follows:
“It's how the nine principles link together to show how we have improved our overall service delivery...” (DOH,2016:12),
This principle in particular highlights the need to monitor improvements in service delivery within the public sector. Therefore, the evaluation of services from the patient’s perspective to determine quality and QI is receiving stronger support from the NSM’s as reflected in the findings of the present study. The findings reveal that patient experience can be a useful measure in quality and QI.
Sub Theme: Patient Experience to Drive Quality Improvement and Positive Reform
Respondents have indicated that measuring patient experience enables them to develop QI programs. Through an evaluation of the patient's experience they are also able to determine whether the QI programs are actually improving the experience of the patient or not. The
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respondents have also indicated that when the QI programs developed from the patient experience data are implemented, it has the potential to promote positive changes in the clinic that translate to positive reforms. This is noted by De Silva who makes mention "that measuring patient experience is important not only to guide quality and service improvement, but also because people’s experiences of care may be linked to clinical outcomes and costs" (De Silva, 2013:199).
Therefore incorporating patient experience in the drive for QI and positive reform is relevant within the context of the public sector. For example, when considering the aspect of clinical outcomes, patient experience has been well linked with the patient's commitment to medication and treatment protocols. In the case of SA where there is a high burden of disease, there is a need for patients to commit to the health process to support better health for all and to also reduce the burden in the long run. For example, patients that are diagnosed with Tuberculosis (TB) are required to complete the full course of TB medication in order to reduce the incidence of Multi Drug Resistant (MDR) TB. When the patient does not complete the full course of medication and develops MDR TB, the patients' management now places a greater economic burden on the health system and the risk of infection spread among family and friends may increase. Studies show that when patients have a negative experience, they become non compliant in the management of their conditions and this has the potential to reduce the clinical outcome of the patient (Sa´nchez-Piedra, Prado-Galbarro, Garcıa-Perez,2014:147).
In the case of organisational costs, patient experience is a useful measure to also understand transient changes in cost and management accounting within various aspects of the health organisation. For example, De Silva found a positive association between experiences of care employee retention (De Silva,2013:200). According to Browne et al. (2010:923) efforts to improve patient experience also result in greater employee satisfaction thereby reducing turnover. Costs related to employee turnover can be felt by all stakeholders. Inadequate staffing places an undue burden on staff to perform in stressful work conditions. This can lead to job dissatisfaction and also may affect the way in which the healthcare staff interacts with the patients and with their colleagues. Within the public sector, the problem of employee turnover and healthcare worker migration has received much attention. Therefore, this is an important
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finding as it shows that patient experience can be linked to employee retention. This link highlights how patient experience influences the cost component.
According to Ahmed et al. (2014:15) collecting experience of care data to stimulate QI is becoming popular. The data collected through patient experience surveys are acknowledged as an important parameter of quality (Lehrman, Silvera and Wolf, 2014:10). Based on the feedback of the present study, the measure of patient experience is important in the drive for QI and positive reform. Therefore the findings of the study are in agreement with Ahmed et al. and Lehrman et al. which show the importance of patience experience in the drive for QI. There are various reasons why feedback from patients may be considered useful in the quest for QI and positive reform. The finding of the present study is in agreement with the findings of Robert and Cornwall. The authors explain that these can include but are not limited to the following:
• "understanding current problems in care delivery;
• informing continuous improvement and redesign of services;
• helping professionals reflect on their own and their team’s practice;
• monitoring the impact of any changes;
• facilitating benchmarking between services/organisations;
• comparing organisations for performance assessment purposes;
• informing referring clinicians about the quality of services;
• informing commissioners and patients about the quality of services;
• informing patients about care pathways;
• helping patients choose high quality providers; and
• enabling public accountability "(Robert and Cornwall,2013:67)
In addition to the findings of Robert and Cornwall, the standards and norms of the DOH (2016:27) state the following with regards to the perception of services:
“Community perception of services should be tested at least twice a year through patient interviews or anonymous patient questionnaires”.
Simply stated, the patients within the community should be given an opportunity to provide feedback that speaks to driving QI via the experience that they have previously encountered.
However, the questionnaire presently in use by the DoH to obtain patient feedback, has not taken
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into consideration the various domains that influence the experience of care, but is rather designed to evaluate patient satisfaction which has been shown to be outdated and less valuable when the issue of quality is raised (National Institute for Health and Clinical Excellence, 2012:10). Based on the Picker Principles and the IOM Framework there is evidence to suggest that there are other domains that need to be included when evaluating the experience of the patient (Picker Principles,2014; IOM Framework,2001).
The questionnaire presently in use caters for just six domains that influence patient satisfaction and is lacking in this regard. The domains are as follows:
• Attitudes of staff;
• Waiting Times;
• Cleanliness of the facility;
• Availability of basic medicines/ supplies;
• Safety and security of the facility; and
• Quality of Care.
Questionnaires are given to patients as part of the service delivery evaluation process but the relevance of the questions included in the questionnaire is also questionable. The importance of the right questions being asked so that the right information can be obtained to aid in the QI process is key, to quality care. The present questionnaire in use is lacking in this regard which creates a gap in terms of obtaining the right information. Hence the need for this study has been further highlighted. Through the study, the domains of patient experience as deemed relevant by both the NSM and the patient is determined. Therefore patient experience is identified as a valuable measure for quality and the QI process within the healthcare environment. There is a definite agreement between the respondents that support the drive for QI and positive reform.
The literature presented also supports the need for incorporating patient experience in the drive for QI and positive reform.