Family involvement and patient-experienced improvement and satisfaction with care: a nationwide cross-sectional study in Danish psychiatric hospitals.

BACKGROUND: Randomised controlled trials suggest that family therapy has a positive effect on the course of depression, schizophrenia and anorexia nervosa. However, it is largely unknown whether a positive link also exists between caregiver involvement and patient outcome in everyday psychiatric hospital care, using information reported directly from patients, i.e. patient-reported experience measures (PREM), and their caregivers. The objective of this study is to examine whether caregiver-reported involvement is associated with PREM regarding patient improvement and overall satisfaction with care. METHODS: Using data from the National Survey of Psychiatric Patient Experiences 2018, we conducted a nationwide cross-sectional study in Danish psychiatric hospitals including patients and their caregivers who had been in contact with the hospital (n = 940 patients, n = 1008 caregivers). A unique patient identifier on the two distinct questionnaires for the patient and their caregiver enabled unambiguous linkage of data. In relation to PREM, five aspects of caregiver involvement were analysed using logistic regression with adjustment for patient age, sex and diagnosis. RESULTS: We consistently find that high caregiver-reported involvement is statistically significantly associated with high patient-reported improvement and overall satisfaction with care with odds ratios (OR) ranging from 1.69 (95% confidence interval (CI) 0.95-2.99) to 4.09 (95% CI 2.48-6.76). This applies to the following aspects of caregiver-reported involvement: support for the patient-caregiver relationship, caregiver information, consideration for caregiver experiences and the involvement of caregivers in decision making. No statistically significant association is observed regarding whether caregivers talk to the staff about their expectations for the hospital contact. CONCLUSION: This nationwide study implies that caregiver involvement focusing on the patient-caregiver relationship is positively associated with patient improvement and overall satisfaction with care in everyday psychiatric hospital care.

Exploring organisational mechanisms in PRO-based follow-up in routine outpatient care - an interpretive description of the clinician perspective.

BACKGROUND: Patient-reported outcome (PRO)-based follow-up is a new model of service delivery, where PRO measures are used as the very basis for demand-driven outpatient follow-up in patients with chronic diseases. Adopting the clinicians' perspective, we aimed to explore what happens when PRO-based follow-up is implemented in routine clinical practice. We also aimed to identify organisational mechanisms related to PRO-based follow-up. METHODS: The methodological approach of this interview study is interpretive description, informed by a perspective of critical realism. Semi-structured interviews were conducted with 13 clinicians (eight nurses and five physicians) working with PRO-based follow-up in outpatient care for epilepsy in the Central Denmark Region. RESULTS: PRO-based follow-up gave rise to ambivalence in clinicians. Seen from the clinicians' perspective, PRO-based follow-up could both increase and decrease the quality of follow-up. Moreover, PRO-based follow-up both enhanced and impaired clinicians' work experiences. Additionally, the clinicians used strategies to ease some of the perceived disadvantages. The clinicians did extra tasks and worked around the scope of PRO-based follow-up. Thus, clinicians constituted a professional buffer as they deflected some of the negative mechanisms associated with PRO-based follow-up. CONCLUSIONS: As a model of a service delivery, PRO-based follow-up is highly dependent on the clinicians' day-to-day management of the system, and mechanisms related to routine use of PRO measures in outpatient follow-up are complex. Paying attention to the organisational settings is critical for PRO-based follow-up to improve quality of care and enhance patient-centred care.

The value of open-ended questions in surveys on patient experience: number of comments and perceived usefulness from a hospital perspective.

OBJECTIVE: To analyse the patients' inclination to comment in generic patient surveys, and to evaluate how these comments were received and used for quality improvement by the hospitals. DESIGN: The study is based on quantitative and qualitative data from four rounds of patient satisfaction surveys from 1999 to 2006. The open-ended questions and their applicability were evaluated by hospital and department management teams in a survey and by hospital employees and leaders, in semi-structured interviews. SETTING: Eight public hospitals in a Danish county (amt). PARTICIPANTS: In this study, the participants were 75 769 patients, 173 department/hospital management teams, and 24 hospital employees and leaders. INTERVENTIONS: Questionnaires with open-ended questions to patients and hospital/department management teams. Semi-structured interviews with hospital employees and leaders. Main outcome measure The number of comments from patients and the usefulness of the comments as perceived by employees and leaders. RESULTS: A total of 76% of the patients chose to add one or more comments to their questionnaires. The patients' inclination to comment increased over time. The patient's inclination to comment was highest for the most and the least satisfied patients. The comment-gathering was viewed as 'Very useful' or 'Useful' by 80.7% of the department management teams (31 responses). CONCLUSION: To gather comments and to forward these to small organizational entities seems to make patient satisfaction measurements more informative and patient-centred. The wording of the open-ended questions, the number of questions and an appeal in the cover letter appear to be important in relation to the patient's inclination to comment.

Semi-customizing patient surveys: linking results and organizational conditions.

OBJECTIVE: The study investigated the needs and consequences of semi-customizing patient satisfaction surveys to low organizational levels and explored whether patient satisfaction was correlated with local organizational conditions. DESIGN: From 1999 to 2006, the County of Aarhus carried out 398 surveys during four rounds in eight hospitals. To explain differences between the wards, data on the 40 wards with the best and the 40 wards with the worst evaluations (identified by patient surveys) were compared with the data from job satisfaction surveys and management information systems. SETTING: Eight public hospitals in a Danish county. PARTICIPANTS: 32,809 inpatients and 1842 nurses on 84 wards. MAIN OUTCOME MEASURE: Optimal organizational level for measuring patient satisfaction and correlations between overall patient satisfaction and organizational context. RESULTS: In all, 71.4% of the departments chose to have the survey results specified at the subunit level or for specific diagnostic groups. Substantial differences in patient satisfaction between wards are illustrated. On the wards with the highest improvement potential, we found significantly higher occupancy rates, acute rates, rates of sickness absenteeism, staff perceptions of high workload and low experience of professionalism. CONCLUSIONS: The study confirmed that departments desired individual, detailed descriptions of the results. Differences in patient satisfaction were associated with differences in organizational conditions. Establishing a link between patient satisfaction and organizational variables broadens the quality development focus to include more than simply analysis of specific questions. Semi-customizing patient surveys are recommended.

Referral of paediatric patients follows geographic borders of administrative units.

INTRODUCTION: This observational study examines changes in paediatric hospital-seeking behaviour at Kolding Hospital in The Region of Southern Denmark (RSD) following a major change in administrative units in Denmark on 1 January 2007. MATERIAL AND METHODS: Data on the paediatric admissions from 2004 to 2009 reported by department of paediatrics and municipalities were drawn from the Danish National Hospital Registration. Patient hospital-seeking behaviour was related to changes in the political/administrative units. Changes in number of admissions were compared with distances to the corresponding departments. RESULTS: From 2006 to 2009, the number of acute and planned admissions at the Department of Paediatrics in Kolding for children living in the RSD increased by 46.1% and 65.0%, respectively. The corresponding changes for children living in the neighboring region, the Central Denmark Region (CDR), were -69.9% and -78.6%. CONCLUSION: The geographical location of the department under study and the changes in administrative units created a "natural experiment" that showed major changes in paediatric hospital-seeking behaviour. Within the RSD, the free choice of hospitals seemed to work, whereas the new boundary between the CDR and the RSD meant that paediatric patients were admitted at hospitals situated in the CDR even though the distances to these hospitals were considerably longer than those to other hospitals. One could question whether patients really have a free choice across administrative borders as political and economic concerns seemed to outweigh free patient choice. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Patient-reported outcome measures in the interaction between patient and clinician - a multi-perspective qualitative study.

BACKGROUND: This article addresses patient-reported outcome (PRO)-based follow-up used as a substitute for regularly scheduled follow-ups. In PRO-based follow-up, patients' PRO data filled in by the patients at home are used by clinicians as a decision aid to identify those who need clinical attention based on an automated PRO algorithm, clinical attention being either a phone call or a physical consultation. A physical consultation in the outpatient clinic prompted by the patient's PRO is termed a "PRO consultation." In this multi-perspective qualitative study, we explored the influence of patients' self-reported data on patient-clinician interaction during PRO consultations in epilepsy outpatient clinics. Interpretive description was the methodological approach, applying data from participant observations, informal interviews with clinicians, and semi-structured interviews with clinicians and patients. RESULTS: We found that application and deliberate use of patients' PRO measures can affect patient-clinician interaction, promoting patient involvement in terms of improved communication and increased patient activation. These findings reflect the general patterns that have been reported in the literature. In addition, we found that PRO measures also may induce unmet expectations among some patients that can have a negative effect on patients' experiences of the interaction and their follow-up experience in general. We extracted two thematic patterns that represent PRO measures' potential for patient involvement in the patient-clinician interaction. The first pattern represents enablers, and the second pattern represents barriers for PRO measures to affect patient involvement. CONCLUSIONS: Applying PRO measures in clinical practice does not automatically enhance the patient-clinician interaction. To strengthen the benefits of PRO measures, the following supplementary clinical initiatives are suggested: summarizing and reporting the PRO measures back to the patient, considering carefully which PRO measures to include, training clinicians and assuring that the patients' introduction to PRO-based follow-up clarifies expectations.

PRO-based follow-up as a means of self-management support - an interpretive description of the patient perspective.

BACKGROUND: There is an increasing focus on the use of patient-reported outcome (PRO) measures to improve the quality and effectiveness of health care. PRO-based follow-up is a new model of service delivery, where the patient's PRO measures are used as the very basis for outpatient follow-up. OBJECTIVES: This study aimed to explore how patients with epilepsy experience the use of PRO-based follow-up in three outpatient clinics in the Central Denmark Region. We also sought to explain how these experiences relate to self-management. METHODS: Interpretive description was the methodological approach. We conducted in-depth individual interviews with 29 patients referred to PRO-based follow-up, each of whom had completed at least two PRO questionnaires. Participants were sampled based on purposive and theoretical sampling. RESULTS: PRO-based follow-up may support patients' self-management by a) increasing awareness of psychosocial problems, b) improving communication, c) increasing understanding of symptoms, d) facilitating change in health behavior and e) strengthening autonomy. Inhibitors for PRO measures as a means of self-management support were identified as a) feelings of rejection and disconnection, b) incomprehension of purpose of PRO-based follow-up, c) PRO measures being too standardized and negative and d) lack of confidence in own ability to assess PRO questionnaires. CONCLUSION: The findings demonstrate broad variation in the influences of PRO measures on patient's self-management in life with epilepsy. Sense of ownership may explain this variation. We suggest supplementary clinical initiatives in order to enhance the benefits from PRO-based follow-up, particularly on how patients are allocated to this health care service.

[Successful patient-activated help call for a doctor during in-hospital stay].

Department of Medicine, Randers Regional Hospital, conducted a study of patient-activated help call, involving 1,050 patients with nearly 3,700 days in-hospital stay. Patients were encou-raged to bypass traditional clinical hierarchy of communication when they felt, that their concern was not met by the staff. Three help calls were related to the management of pain. In two cases it resulted in a surgical procedure. A survey including 104 patients revealed that one third reported that patient safety was improved by the initiative and nearly three quarters re-ported that they would be willing to activate the call.

A Danish adaptation of the quality in psychiatric care-forensic in-patient questionnaire: psychometric properties and factor structure.

OBJECTIVE: The aims of this study were to adapt and evaluate the psychometric properties and factor structure of the Danish version of the Quality in Psychiatric Care-Forensic In-Patient (QPC-FIP) questionnaire. METHODS: A sample of 139 inpatients from 25 wards in Denmark who received care during 5 weeks in March and April 2012 participated in the study by completing the QPC-FIP instrument. RESULTS: Confirmatory factor analysis revealed that the factor structure of the Danish version was equivalent to that of the original Swedish QPC-FIP. The results indicate that the concept of quality of care expressed in the QPC-FIP is equivalent among forensic inpatients in nationally different healthcare systems and cultural contexts. CONCLUSION: The Danish version of QPC-FIP is a reliable and valid measurement instrument recommended for use in evaluating quality of care in forensic inpatient care.

Hospitals need to customise care according to patients' differing information-seeking behaviour.

INTRODUCTION: The aim of the study was to describe how often patients seek information about their disease in connection with contact to a hospital and to elucidate how information-seeking behaviour is related to the patients' perception of this contact. MATERIAL AND METHODS: The study was based on patient surveys from the Danish county of Aarhus from 1999 to 2006 including eight public hospitals. The patients' information-seeking behaviour was related to patient characteristics, organisational context and patient perceptions. RESULTS: Among the 75,769 patients who responded, 33.4% had actively sought information. The frequency of patients seeking information increased from 24.4% in 1999 to 38.3% in 2006 with a variation between organisational units ranging from 7.7% to 81.8%. The share of critical patients among those who actively sought information was 23.7% in 1999 and 18.1% in 2006 compared with 12.9% and 11.3% critical patients, respectively, among those who did not. CONCLUSION: Having sought information correlated with negative patient perceptions. Despite convergence, differences between the perceptions of active and passive information seekers still remain. The health-care system should be prepared to serve patients who have different levels of knowledge. PRACTICE IMPLICATIONS: The health-care system should continuously improve the service provided to patients with different levels of knowledge and different attitudes towards involvement. It is recommended to routinely ask patients about their information seeking and to include questions about patients' information-seeking behaviour in patient satisfaction surveys. FUNDING: Financial support for the research and preparation of this article was provided by TrygFonden, Momsfonden and the Region of Central Jutland. None of the funding sources had any involvement in the study design, the analysis and interpretation of data, the writing of the report, or the decision to submit the paper for publication. TRIAL REGISTRATION: not relevant.

Use of Patient-Reported Outcome (PRO) Measures at Group and Patient Levels: Experiences From the Generic Integrated PRO System, WestChronic.

BACKGROUND: Patient-reported outcome (PRO) measures may be used at a group level for research and quality improvement and at the individual patient level to support clinical decision making and ensure efficient use of resources. The challenges involved in implementing PRO measures are mostly the same regardless of aims and diagnostic groups and include logistic feasibility, high response rates, robustness, and ability to adapt to the needs of patient groups and settings. If generic PRO systems can adapt to specific needs, advanced technology can be shared between medical specialties and for different aims. OBJECTIVE: We describe methodological, organizational, and practical experiences with a generic PRO system, WestChronic, which is in use among a range of diagnostic groups and for a range of purposes. METHODS: The WestChronic system supports PRO data collection, with integration of Web and paper PRO questionnaires (mixed-mode) and automated procedures that enable adherence to implementation-specific schedules for the collection of PRO. For analysis, we divided functionalities into four elements: basic PRO data collection and logistics, PRO-based clinical decision support, PRO-based automated decision algorithms, and other forms of communication. While the first element is ubiquitous, the others are optional and only applicable at a patient level. Methodological and organizational experiences were described according to each element. RESULTS: WestChronic has, to date, been implemented in 22 PRO projects within 18 diagnostic groups, including cardiology, neurology, rheumatology, nephrology, orthopedic surgery, gynecology, oncology, and psychiatry. The aims of the individual projects included epidemiological research, quality improvement, hospital evaluation, clinical decision support, efficient use of outpatient clinic resources, and screening for side effects and comorbidity. In total 30,174 patients have been included, and 59,232 PRO assessments have been collected using 92 different PRO questionnaires. Response rates of up to 93% were achieved for first-round questionnaires and up to 99% during follow-up. For 6 diagnostic groups, PRO data were displayed graphically to the clinician to facilitate flagging of important symptoms and decision support, and in 5 diagnostic groups PRO data were used for automatic algorithm-based decisions. CONCLUSIONS: WestChronic has allowed the implementation of all proposed protocol for data collection and processing. The system has achieved high response rates, and longitudinal attrition is limited. The relevance of the questions, the mixed-mode principle, and automated procedures has contributed to the high response rates. Furthermore, development and implementation of a number of approaches and methods for clinical use of PRO has been possible without challenging the generic property. Generic multipurpose PRO systems may enable sharing of automated and efficient logistics, optimal response rates, and other advanced options for PRO data collection and processing, while still allowing adaptation to specific aims and patient groups.

Positive patients' attitudes to prehospital care.

INTRODUCTION: The aim of the study was to elucidate the patients' perceptions of the whole prehospital "chain-of survival" from the 1-1-2 call was made to arrival at the hospital; we wanted to study especially the impact different urgency levels had on patients' overall impression. MATERIAL AND METHODS: The study was based on 1-1-2 medical emergency calls and forms a part of a larger postal survey among 6,535 patients who requested and received ambulance services. The answers were dichotomized into "problem scores" and "non-problem scores". The patients' overall impression was analysed in logistic regression models. RESULTS: The study was based on 1,419 answers (response rate 58%). Overall, 98% of 1-1-2-patients characterized the prehospital care as "Very good" (82%) or "Good" (16%). Patients' overall perceptions were dependent on age, evaluated urgency, and the information they received about expected response time. Patients' self-evaluated urgency level was lower than that assessed by the prehospital. CONCLUSION: The study shows that patients have a very positive attitude towards prehospital care, including criteria-based medical dispatch of ambulances. The overall impression of patients with urgency level A was significantly better than that of patients with urgency level B. The issues with most potential for improvement are: the assistance provided when calling 1-1-2 (first answered by the police and then the medical personnel), the prehospital personnel explaining what they were doing, the involvement of relatives and better information about expected ambulance response time. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[The Internet influences the patient-physician relationship]. / Internettet påvirker læge-patient-relationen.

So far, we have only limited knowledge on how the patients' use of the Internet affects consultations. A review of 36 empirically based articles from 1999 to 2009 demonstrates that patients' Internet search for health information is widespread. However, there are signs that the impact of Internet searches on consultations is limited as a number of factors reduce the probability of an effect on the dialogue between physician and patient. Results are discussed with reference to three classic consultation models: the paternalistic, the partnership and the consumer model.

[Can patient satisfaction change over time?]. / Kan patienttilfredshed udvikle sig over tid?

INTRODUCTION: Though use of repeated generic measurements of patient satisfaction is increasing, we have limited knowledge of how results change over time. The present study focused on systematic changes of inpatients' satisfaction both at high and low organizational levels, and addressed the question of whether there is an association to occupancy rates, acute rates and local leaders' evaluation of the concept for monitoring patient satisfaction. MATERIAL AND METHODS: During the period from 1999 to 2006, the County of Aarhus carried out detailed patient satisfaction surveys over four periods in eight somatic hospitals. The 71 wards participating in the first three periods were included. Organizational data were drawn from a management information system. A questionnaire to heads of department and hospital was used to evaluate the concept after each period. RESULTS: At county level there was no significant development in satisfaction during the period. However, the wards with the lowest evaluations from the first round experienced significant and persisting improvements over the next two periods. The wards which experienced significant improvements were characterised by having few acute patients. CONCLUSION: The study shows that patient satisfaction can change over time. There seems to be a positive effect associated with first time measurements on a detailed organizational level. Persistent improvements of patient satisfaction were seen on the wards with lowest satisfaction at baseline, indicating that the concept seems to have a positive impact on performance. Wards with a high acute rate seem to have difficulties in improving patient satisfaction.

[Patient satisfaction in relation to organizational conditions]. / Patienttilfredshed set i relation til organisatoriske forhold.

INTRODUCTION: Measuring patient satisfaction is increasingly done by generic standardized instruments in the context of which follow-up has been reported as problematic. The aim of the study was to investigate if a more customized design would make patient satisfaction surveys more interesting and useful for the clinicians. MATERIAL AND METHODS: During the period 1999-2006, the County of Aarhus carried out 398 surveys in four rounds at the County's eight hospitals. On the basis of these evaluations, we have analysed the departments' need for detailed results and the potential for ward level improvement. To explain differences between wards, the 40 wards with the best and the 40 wards with the worst evaluations from round three were compared with data from job satisfaction surveys and a management information system. RESULTS: 71.4% of the departments chose to have the results specified at ward level or associated with specific diagnosis groups. The potential for improvement for the different wards showed variations among the survey questions from 0.0 to 72.3%. At the wards with the highest potential for improvement, we found significantly higher occupancy rates, acute rates, rates of sickness absenteeism and staff perception of high work load, and also less experience of professionalism. CONCLUSION: The study confirmed that departments wanted individual and detailed presentations of the results, and that differences in patient satisfaction were associated with differences in organizational conditions. Lack of follow-up is, among others, ascribed to a lack of precision and doubtful value of results as a consequence of a measurement at a too high organizational level.

[An evaluation of patient satisfaction surveys by heads of hospitals and departments]. / Sygehus- og afdelingsledelsers evaluering af patienttilfredshedsundersøgelser.

INTRODUCTION: The point of departure is that patient satisfaction surveys should be designed and organized in a manner that furthers ownership and responsibility ensuring follow-up by those who are to employ the results. This study therefore evaluates the perceived usefulness of patient satisfaction surveys among heads of departments and heads of hospitals. MATERIAL AND METHODS: During the period from 1999 to 2006, the County of Aarhus performed four patient survey series. After each series, heads of department and heads of hospital were asked to fill out questionnaires to evaluate the entire system. A total of 200 questionnaires were sent and 173 were returned (86.5%) with 640 comments to the open-ended questions. RESULTS: 82.5% of the leaders evaluated the concept as "Outstanding" or "Good". Leaders from teaching hospitals and heads of hospital were more satisfied. The highest scores were given for the option of having the results reported at ward level and/or diagnostic groups, and the option of collecting comments from patients. 82.4% of the leaders reported that the surveys had resulted in concrete follow-up activities. The main criticism of the concept was its lack of detail. CONCLUSION: Generic patient satisfaction surveys can gain acceptance from the involved leaders. In part, the acceptance of the users is based on their possibilities of making individual choices within the standardized questionnaires. It is recommended to involve users of patient satisfaction surveys in the design and evaluation of concepts in the future, including frontline staff.

Patient surveys--a key to organizational change?

OBJECTIVE: The objective was to investigate whether semi-customized patient satisfaction surveys are seen as useful by hospital management, and to explore their possible effects on quality improvement over time at a low organizational level. METHODS: Data were collected from three sources: (1) patient surveys administered in eight public hospitals with a total of 2200 beds in a Danish county; (2) questionnaires completed by the hospital and clinical department managers; and (3) data from the county's Management Information System. RESULTS: Patient satisfaction surveys were widely accepted as a tool for change. Bad results seemed to be an incentive for improvement unless hindered by fluctuation in patient turnover. Acceptance of the patient surveys as a way to generate change diminished over time. CONCLUSION: Patient surveys may be an incentive for change if: (1) they have sufficient validity; (2) feedback is detailed on an organizational level and the units have significantly lower scores than comparable units; and (3) there are obvious actions to address the problems. PRACTICAL IMPLICATIONS: Both qualitative and quantitative results should be analyzed for small organizational units within hospitals. Perceived usefulness of the surveys may be increased by involving medical professionals in the design and evaluation of the survey system.