Structure, process or outcome: which contributes most to patients’ overall assessment of healthcare quality? BMJ Qual Saf

Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
BMJ quality & safety (Impact Factor: 3.99). 02/2011; 20(4):326-31. DOI: 10.1136/bmjqs.2010.042358
Source: PubMed


The paper explores which type of quality aspects (structure, process, outcome) most strongly determines patients' overall assessment of healthcare, and whether there is a variation between different types of patient groups in this respect.
Secondary analyses were undertaken on survey data from patients who underwent hip or knee surgery, cataract surgery, patients suffering from varicose veins, spinal disc herniation or rheumatoid arthritis. In these analyses, the patient-given global rating served as the dependent variable, and experiences regarding structure (waiting times, continuity of care), process (doctor-patient communication and information) and outcome aspects (improvement or worsening of symptoms) served as independent variables.
Experiences regarding process aspects explained most of the variance in the global rating (16.4-23.3%), followed by structure aspects (8.1-21.0%). Experiences regarding outcome did not explain much variance in the global rating in any of the patient groups (5.3-13.5%). The patient groups did not differ with respect to the type of quality aspects that most predicted the overall assessment.
Improving process and structure aspects of healthcare is most likely to increase patients' overall evaluation of the quality of care as expressed in a global rating. A more sophisticated method of patient reported outcome measurement, with pre- and post-treatment questionnaires and the inclusion of quality-of-life criteria, might lead to higher associations between outcome and the overall evaluation of the received care.

Download full-text


Available from: Jany Rademakers, Jun 30, 2014
46 Reads
  • Source
    • "Assessing patient experiences of the quality of care not only provides information about the actual experiences, but also reveals which quality aspects patients regard as most important [7]. Many studies have been performed to analyse what patients consider essential within healthcare [8-10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Healthcare organisations monitor patient experiences in order to evaluate and improve the quality of care. Because nurses spend a lot of time with patients, they have a major impact on patient experiences. To improve patient experiences of the quality of care, nurses need to know what factors within the nursing work environment are of influence. The main focus of this research was to comprehend the views of Dutch nurses on how their work and their work environment contribute to positive patient experiences. Methods A descriptive qualitative research design was used to collect data. Four focus groups were conducted, one each with 6 or 7 registered nurses in mental health care, hospital care, home care and nursing home care. A total of 26 nurses were recruited through purposeful sampling. The interviews were audiotaped, transcribed and subjected to thematic analysis. Results The nurses mentioned essential elements that they believe would improve patient experiences of the quality of nursing care: clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patient-centred culture. They also mentioned several inhibiting factors, such as cost-effectiveness policy and transparency goals for external accountability. Nurses feel pressured to increase productivity and report a high administrative workload. They stated that these factors will not improve patient experiences of the quality of nursing care. Conclusions According to participants, a diverse range of elements affect patient experiences of the quality of nursing care. They believe that incorporating these elements into daily nursing practice would result in more positive patient experiences. However, nurses work in a healthcare context in which they have to reconcile cost-efficiency and accountability with their desire to provide nursing care that is based on patient needs and preferences, and they experience a conflict between these two approaches. Nurses must gain autonomy over their own practice in order to improve patient experiences.
    BMC Health Services Research 06/2014; 14(1):249. DOI:10.1186/1472-6963-14-249 · 1.71 Impact Factor
  • Source
    • "Research has shown that the global rating largely represents patients’ experiences with the process of care (e.g. communication), even though patients also consider many other aspects of care to be highly relevant [9,14,15]. Thus, there is a substantial risk that a global rating represents only some of the patient experience indicators. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Global ratings of healthcare by patients are a popular way of summarizing patients' experiences. Summary scores can be used for comparing healthcare provider performance and provider rankings. As an alternative, overall scores from actual patient experiences can be constructed as summary scores. This paper addresses the statistical and practical characteristics of overall scores as an alternative to a global rating in summarizing patient survey results. Data from a 2010 patient experience survey for approximately 12,000 nursing home residents (7.5% of all Dutch nursing home residents at the time) from 464 nursing homes in the Netherlands (25% of the Dutch nursing homes) was used. Data was collected through specifically designed standardized interview surveys. The respondents' scores for 15 established quality indicators (or composites) for nursing home care were used to calculate overall scores for each nursing home, using four different strategies. The characteristics of the overall scores were compared against each other and with the respondents' global rating. The individual indicators showed stronger associations with each of the four overall strategies than with the global ratings. Furthermore, the dispersion of the overall scores across nursing homes was greater. Differences between overall scores appeared limited. Overall scores proved more valid than global ratings as a summary of the indicator scores, and also showed more pronounced differences between nursing homes. Because of the limited statistical differences between the strategies, and for practical reasons, a straightforward averaging of quality indicator scores may be preferred as an overall score.
    BMC Health Services Research 11/2013; 13(1):479. DOI:10.1186/1472-6963-13-479 · 1.71 Impact Factor
  • Source
    • "Other factors that are found to influence choice positively are whether the patient is involved in decision making about care (n = 12) [26,34,37,62,76,99] and a friendly provider atmosphere (n = 7) [30,32,33,46,62,76]. Age positively influences the importance attached to interpersonal characteristics according to several studies (n = 6) [26,30,34,76,119,126], while education negatively influences the importance of interpersonal characteristics (n = 6) [26,30,33,34,76,126]. Research into the influence of disease characteristics shows that patients with more complex or severe diseases attach more importance to interpersonal characteristics [26,50,113,129] and that the specific disease influences the importance the patient attaches to interpersonal characteristics [30,80,98,129]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background In several northwest European countries, a demand-driven healthcare system has been implemented that stresses the importance of patient healthcare provider choice. In this study, we are conducting a scoping review aiming to map out what is known about the determinants of patient choice of a wide range of healthcare providers. As far as we know, not many studies are currently available that attempt to draw a general picture of how patients choose a healthcare provider and of the status of research on this subject. This study is therefore a valuable contribution to the growing amount of literature about patient choice. Methods We carried out a specific type of literature review known as a scoping review. Scoping reviews try to examine the breadth of knowledge that is available about a particular topic and therefore do not make selections or apply quality constraints. Firstly, we defined our research questions and searched the literature in Embase, Medline and PubMed. Secondly, we selected the literature, and finally we analysed and summarized the information. Results Our review shows that patients’ choices are determined by a complex interplay between patient and provider characteristics. A variety of patient characteristics determines whether patients make choices, are willing and able to choose, and how they choose. Patients take account of a variety of structural, process and outcome characteristics of providers, differing in the relative importance they attach to these characteristics. Conclusions There is no such thing as the typical patient: different patients make different choices in different situations. Comparative information seems to have a relatively limited influence on the choices made by many patients and patients base their decisions on a variety of provider characteristics instead of solely on outcome characteristics. The assumptions made in health policy about patient choice may therefore be an oversimplification of reality. Several knowledge gaps were identified that need follow-up research.
    BMC Health Services Research 08/2012; 12(1):272. DOI:10.1186/1472-6963-12-272 · 1.71 Impact Factor
Show more