Item generation in the development of an inpatient experience questionnaire: a qualitative study

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    Item generation in the development of aninpatient experience questionnaire: a qualitativestudyEliza LY Wong1*, Angela Coulter2, Annie WL Cheung1, Carrie HK Yam1, Eng-Kiong Yeoh1 and Sian Griffiths1


    Background: Patient experience is a key feature of quality improvement in modern health-care delivery. Measuringpatient experience is one of several tools used to assess and monitor the quality of health services. This study aimsto develop a tool for assessing patient experience with inpatient care in public hospitals in Hong Kong.

    Methods: Based on the General Inpatient Questionnaire (GIQ) framework of the Care Quality Commission as adiscussion guide, a qualitative study involving focus group discussions and in-depth individual interviews withpatients was employed to develop a tool for measuring inpatient experience in Hong Kong.

    Results: All participants agreed that a patient satisfaction survey is an important platform for collecting patientsviews on improving the quality of health-care services. Findings of the focus group discussions and in-depthindividual interviews identified nine key themes as important hospital quality indicators: prompt access, informationprovision, care and involvement in decision making, physical and emotional needs, coordination of care, respectand privacy, environment and facilities, handling of patient feedback, and overall care from health-care professionalsand quality of care. Privacy, complaint mechanisms, patient involvement, and information provision were furtherhighlighted as particularly important areas for item revision by the in-depth individual interviews. Thus, the initialversion of the Hong Kong Inpatient Experience Questionnaire (HKIEQ), comprising 58 core items under ninethemes, was developed.

    Conclusions: A set of dimensions and core items of the HKIEQ was developed and the instrument will undergovalidity and reliability tests through a validation survey. A valid and reliable tool is important in accurately assessingpatient experience with care delivery in hospitals to improve the quality of health-care services.

    Keywords: Patient experience, Patient satisfaction survey, Inpatient experience questionnaire

    BackgroundAccurate diagnosis, advance treatment, and low mortalityrate are no longer sufficient when considering quality ofhealth care [1]. Health-care institutions need to go beyondthe medical point of view and must likewise considerhospitalization experiences from the perspective of pa-tients. Because of the growing demand for patient-centeredcare, measurement of patient experience is becoming in-creasingly recognized as an important indicator of health-care quality, including the effectiveness, efficiency, and

    safety of care [2-5]. Studies around the world have shownthat positive patient experience directly influence severalimportant aspects of care, including compliance with treat-ment and continuity of care [6], disclosure of importantmedical information to physicians, reduction of complaintsagainst institutions, improvement of morale, and job satis-faction among health-care providers [7-9], which in turnbenefit the health of patients and promote a positive work-ing atmosphere within health-care organizations [10-16].The current health-care climate mandates an objective

    assessment and public reporting of patient experienceinstead of simply reporting a satisfaction score [17].Patient experience with care can provide information forquality improvement [5] that is more detailed than a

    * Correspondence: Jockey Club School of Public Health and Primary Care Faculty ofMedicine, The Chinese University of Hong Kong, Hong Kong, ChinaFull list of author information is available at the end of the article

    2013 Wong et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (, which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

    Wong et al. BMC Health Services Research 2013, 13:265

  • patient satisfaction score and can be incorporated intothe measurement of patient experience to reflect thepreferences or expectations of patients regarding healthcare [17]. The complex nature of patient experience ofcare implies that the dimensions to be investigated shouldbe identified from the patients perspective. Studies havehighlighted that definition of quality, measurement ofquality, and routine quality assessment and improvementwere important steps toward incorporating the patientsperspective [18]. In addition to patient satisfaction scores,understanding the needs, preferences, and expectations ofpatients regarding health-care services are therefore im-portant in developing a measuring tool.In the last decade, a number of tools for measuring

    patient experience in hospitals have been developed,employing various criteria to determine validity [19-21].A review study has showed that nine ongoing patientexperience and satisfaction survey programs had un-dertaken in 2008 including the Canadian CommunityHealth Survey (CCHS), The Commonwealth Fund byUSA, Consumer Assessment of Healthcare Providersand System by USA, Department of Quality Measure-ment by Demark, Dutch Centre for Consumer Experi-ence in Health Care, Norwegian Knowledge Centre forthe Health Services, Picker Institute Europe, Unit ofPatient Evaluation by Demark, and the World HealthOrganization (WHO) program [22]. The United Kingdom(UK) (National Health Service Patient Survey Program),the United States (US) (Hospital Consumer Assessmentof Health-care Providers and Systems), and Australia(Victorian Patient Satisfaction Monitor) have developedtools for measuring inpatient satisfaction, and surveys atthe national level have been regularly conducted in thesecountries [23-25]. These three tools cover similar aspects,including accessibility, physical environment, communica-tion, interpersonal relationship, and discharge procedureand information. The General Inpatient Questionnaire(GIQ) of the UK Care Quality Commission further em-phasizes care coordination and continuity from hospitalsto communities, whereas the US Hospital ConsumerAssessment of Health Plan Survey (HCAHPS) includespain management. The Australian Patient SatisfactionQuestionnaire (PSQ) highlights the mechanism of com-plaint management [23-26]. The Netherlands has devel-oped the Consumer Quality Index, based on a US tool, theConsumer Assessment of Health-care Providers and Sys-tems, and an earlier Dutch tool, Quality of Care throughthe Patients Eyes, as a standardized method for measuringpatient experience with health-care providers and healthplans [27,28]. The Hong Kong Hospital Authority (HA)commissions patient satisfaction surveys on a regular basisas a quality improvement mechanism. A standard and val-idated patient-satisfaction survey tool is a prerequisite. Ac-curately identifying service areas for quality improvement

    and for external accountability and public reporting isimportant [5,29,30]. By considering different health-caresystems, patient expectations, and value and culturalneeds, an instrument was developed for the Hong Kongcontext, thus making this instrument a valid and reliabletool for patients to respond to [29-34].In Hong Kong, the HA, a public organization, is

    responsible for more than 90% of hospital services. Hos-pital services are organized into seven clusters, with eachcluster serving a geographical region with a populationof around one million. Each cluster has one or moreacute hospitals that admit seriously ill patients fromemergency units, and one or more rehabilitation hospi-tals that admit transfer patients from acute hospitals forrehabilitation and convalescence [35]. In 2007, the HongKong government adopted the Picker Patient ExperienceQuestionnaire-15 to measure self-reported inpatientexperiences through the Thematic Household Survey.Results of this survey revealed that mean global scoresfor public and private hospitals were 7.3 and 7.8 out of10, respectively [36]. However, generalization is doubtfulbecause the tool used was adopted directly fromoverseas and the health-care setting in Hong Kong isdifferent. A number of hospitals conducted their ownsmall-scale patient satisfaction surveys, but such surveysadopted a piecemeal approach and did not use standard-ized and locally validated questionnaires. Consequently,the validity of the results of these surveys is question-able, and thus these findings cannot be used for com-parison with other hospitals in Hong Kong and in othercountries with regard to health-care quality. A uniquehealth-care structure, the Chinese culture, and differentpatient expectations justify the development of a HongKongbased patient experience questionnaire. This studyaims to develop an instrument for measuring inpatientexperience in Hong Kong. However, the present paper willonly report the development of the instrument; thepsychometric properties of the scale will be discussed in aseparate paper.

    MethodsStudy designQualitative study, including focus group discussionsand individual interviews, was used to develop theinstrument. Available and validated inpatient scales, in-cluding GIQ, HCAHPS, and PSQ used to assess patientexperiences and satisfaction, were reviewed. The GIQdeveloped by the Picker Institute Europe for the na-tional patient survey program in England was adoptedas the framework in our qualitative study because itwas the most comprehensive and had been used as thebasis for developing questionnaires in many countries.Moreover, the hospital setting in England is similar tothat in Hong Kong [37].

    Wong et al. BMC Health Services Research 2013, 13:265 Page 2 of 13

  • Target populationThe target population consisted of Hong Kong citizenswith a Hong Kong Identity Card, aged 18 years old,Cantonese-speaking, and discharged as an inpatientfrom one of 25 major acute and rehabilitation HA hospi-tals from seven geographical clusters within 48 hours toone month prior to interview. Exclusion criteria wereday cases, psychiatric and mentally handicapped pa-tients, and those discharged from specialist units such asobstetrics, dentistry, hospice, infirmary, pediatrics, inten-sive care, anesthesiology, and other departments codedby the HA. Potential participants for both focus groupdiscussion and in-depth individual interview were firstscreened and approached by ward staff based on inclu-sion and exclusion criteria. Once written consent wasobtained, patient information was sent to our researchteam for interview arrangement. At least three focusgroup discussions, with 6 to 8 patients in a group, and 7in-depth individual interviews, comprising patients fromseven clusters, were planned. Both focus group discus-sions and in-depth individual interviews were suspendedonce data became saturated.

    Data collectionA two-step qualitative approach, using focus groupdiscussion and individual interview, was used to developa local questionnaire that considered the culture andhospital environment in Hong Kong. First, focus groupdiscussions were conducted to identify whether dimen-sions derived from the GIQ were relevant and applicableto Hong Kong patients in evaluating hospital care satis-faction and in determining whether any important issueshad not been covered by the GIQ. Then, individual in-terviews were conducted to ensure comprehensiveness,feasibility, and understandability of the questionnaire,which was developed based on the findings of the focusgroup discussions.The GIQ comprised 67 items under eight dimensions,

    namely, prompt access, respect and dignity, informationand education, involvement and choice, physical andemotional needs, coordination of care, environment andfacilities, and overall impression of the experience. Alleight dimensions and their corresponding evaluativeitems were taken from the aforementioned GIQ to es-tablish discussion topics and prompts for the focusgroup discussion. In addition, participants were asked toexpress themselves freely on any issue concerning in-patient care that was important to them. Discussionswere held in two selected hospitals at the convenience ofthe participants, each lasting for approximately 90 to 120minutes. The discussion included three parts, namely,warm-up exercise, themed discussion, and card-sortingexercise. Participants first introduced themselves andbriefly shared their own recent hospitalization experience

    in the warm-up exercise. In the second part, the discus-sion followed eight aspects of care: prompt access, infor-mation and education, involvement and choice, physicaland emotional needs, coordination of care, respect anddignity, environment and facilities, and overall impressionof the experience. Prompts were listed for each theme tofacilitate the discussion. Findings would confirm whetherGIQ dimensions and items were relevant and applicablein Hong Kong. In the card-sorting exercise, participantswere asked to categorize 15 preset aspects of inpatientcare that were adopted to develop the GIQ into threelevels of importance, namely: most important, quite im-portant, and least important. Participants then discussedtheir respective reasons for classification. They were alsoallowed to suggest any important issue not included in thecards. The card-sorting exercise provided information onpatients preferences and priorities for inpatient care forthe development of the instrument. Discussions wereconducted in Cantonese to allow participants to expresstheir ideas freely and were all led by one of the researchers(ELYW).The first draft questionnaire was developed on the

    basis of the findings of the focus group discussions. Theindividual interview was the second qualitative step indeveloping the local inpatient satisfaction questionnaire.This step was important in the validation processbecause it ensured comprehensiveness, feasibility, andunderstandability of the draft questionnaire, which wasdeveloped by incorporating results of the focus groupdiscussions into the structure of the GIQ. In the individ-ual interviews, the participant was required to completethe questionnaire and was then invited to share his/herviews on the tool used to determine his/her hospitalexperiences. Collected views were used to revise itemsto develop comprehensiveness, feasibility, and under-standability of the tool. Interviews were conducted inCantonese by the designated researcher (AWLC) at theconvenience of the participants in a private room toensure that participants would freely express theiropinions.

    Data analysisIn the study, all the qualitative components adhered tothe RATS guidelines. All focus group discussions wererecorded on audio tape, transcribed, and verified againstthe tapes. Thematic analysis based on the discussionguide was performed using Nivo 7.0, and themes wereidenti...


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