Patient Feedback

Feedback loop

Author: Amanda Lyons

Collecting patient feedback can be vital to guiding general practice services and meeting patient needs.

It can be easy for people in any profession to become satisfied with how they do their job and, in turn, fail to consider ways in which they could improve. After all, there is no point in fixing what does not seem to be broken.

GPs and others in general practice are not immune to this thinking; however, patient feedback presents one of the best ways to assess a practice and its processes, and make changes accordingly.

‘It’s about reviewing the systems and services that you offer your patients within your practice. Listening to the comments they might make, considering those comments and, if you can change something, making the change to improve the quality of service,’ Dr Mike Civil, GP, Chair of the RACGP Expert Committee – Standards for General Practices and Australian General Practice Accreditation Limited (AGPAL) surveyor, told Good Practice.

‘I believe that we are there to help our patients and offer a health service to them, and I think patient feedback is crucial to making sure we address what patients think is important in receiving healthcare from us.

‘It boils down to [the possibility that] you think you are offering the right kind of service, you think you’re covering all the bases when you offer general practice services to your patients, but you might not be getting it right.’

 

Up to standard

Collecting and responding to patient feedback is considered such a key aspect of general practice operations that it is enshrined into the RACGP’s Standards for general practices (4th edition) (the Standards).

Patient feedback can help guide the improvement of quality in service delivery, which can then result in better clinical outcomes for patients.¹

While the directive to collect patient feedback has been part of the Standards for some time, developments in technologies have begun to offer new possibilities for ways in which feedback is collected.

‘One of the things I have noticed over the years as an AGPAL surveyor is that practices have tried to be innovative in how they receive and respond to feedback, particularly as there has been more use of different survey technologies,’ Dr Civil said.

Dr Civil has observed that use of more modern tools allows practices to be more agile in response to patient feedback.

‘The practice could get feedback very quickly and say, “Okay, we’ve noted that”,’ he said. ‘If there was something particularly negative, they could respond quickly and make changes, or address a patient query.

‘I think that is a really great way to handle feedback through greater use of technology.’

The current edition of the Standards does not make provision for the use of such technologies in patient feedback collection. However, Dr Civil is keen to correct this in the upcoming 5th edition of the Standards, while also incorporating the fundamentals of feedback and response.

‘One of the things we tried to do with the 5th edition [of the Standards] is go back to the roots of what patient feedback is all about, which is basically asking patients what they think of the services we provide, and then responding and making changes that improve the quality of those services,’ he said.

‘That’s the premise I’ve always seen with the 5th edition of the Standards, in which we’ve been a lot more flexible with how practices receive feedback.

‘We don’t want to completely lose sight of some of those more robust processes, but it is still important to hold on to that fundamental concept, which is to listen to our patients, review what we do and ask, “Could we do it better?”’

 

Greater detail

New South Wales GP Dr Hester Wilson agrees that feedback is important to ensure that practitioners have a ‘patients’ eye’ view of any initiatives they may wish to implement.

‘GPs might come up with some great ideas, but how do we know they’re the right ideas that are going to assist and are important to our patients?’ she said.

To this end, Dr Wilson is the GP advisor for the NSW Agency for Clinical Innovation (ACI) on the Patient Reported Measures (PRM) program, a publicly-funded initiative aimed at gathering more helpful detail on patient feedback.

The PRM program aims to gather direct, timely feedback from patients regarding their health outcomes and experiences, with the goal of driving improvement in healthcare delivery across NSW.

According to Dr Wilson, there are two kinds of PRMs.

‘The first is patient-reported experience measures [PREMs],’ she said. ‘Those are the ones we fill in with our accreditation every three years and which the RACGP is reviewing at the moment.

‘They are not just about patient satisfaction, but also, “What was the quality of the interaction?” “How much were you able to engage in your care, if you wish to do that as a patient?” “What was the quality of the information given?” “What were the formats in which you were given information?”

‘So it’s not only, “Yes, I like my doctor and the waiting room was nice, it was a good experience”. It’s actually trying to look at the quality of the patient’s experience in terms of their care.’

The second type of PRMs are known as patient-reported outcome measures (PROMs), which have a clinical basis. If PREMs help to assess the quality of a patient’s experience after their consultation, PROMs help to identify a patient’s clinical needs before and during treatment. There are currently thousands of PROMs available for medical professionals with which GPs would likely be familiar, such as the Kessler Psychological Distress Scale (K10) and the Depression and Anxiety Stress Scales (DASS21).

Dr Wilson believes there can sometimes be a difference between the goals of practitioners and the goals of patients, and patient feedback is necessary to identify and help these bridge gaps.

‘It’s about that question of what we are actually measuring, and making sure that what we measure is not just what’s important to us as clinicians, but also what’s important to patients,’ she said.

‘For me as the clinician, it may be simply that the medication is working and that patients are improving and not having side effects.

‘But, for the patient, it might also be, “I’m well enough to walk the dog”, or “I’m well enough to play with the kids”.

‘The wonderful thing about measures like these is that you can look at, for example, what DASS score the person got when you first saw them and then, after you’ve done an intervention such as counselling or medication or referral to a focussed psychological strategy, see what the outcome of that has been.

‘So it allows you to see how patients progress over time.’

Dr Wilson has found that using PROMs enables her to have a more concrete measure of the effectiveness of her general practice services. They also provide a common language for GPs and other healthcare professionals.

‘Thinking of the DASS21, for example, if I refer a patient to a psychologist or a mental health social worker and they use the same form, they’ll understand where I’ve come from. There’s that shared language.’

PROMs measures also enable a GP to provide the patient with meaningful feedback.

‘If you’ve got a patient who comes in really depressed and you do the DASS21, when you follow up you can say, “Look where you were when we started and look where you are now”,’ Dr Wilson said.

‘The patient will be aware that there’s been change, but if they’re experiencing depression, change can sometimes be slow. To get a sense of [that change] and to see that in front of you in black and white can be really beneficial.’

The ultimate purpose of the ACI program is to test, design and assess the feasibility of implementing such measures widely in partnership with general practice in NSW, and this is not without its challenges – one of which is simply selecting which outcome measures to use. However, Dr Wilson has some advice.

‘You want to go for the ones that are well-validated and have been competently tested in a similar patient group to yours,’ she said.

‘So you can either go for the global ones, which are general quality of life, or you can go for illness-specific or condition-specific ones.’

It is also important to consider the logistics of implementing the measures in practice.

‘Do you do it before the patient comes in and sees you, or do you do it as part of your consultation? Do you send it out to your patients via email and get them to fill it in before they come in?’ Dr Wilson said.

‘And once you’ve got a PROMs score, you’ve got to make sure that you’re going to do something with it.’

Dr Wilson acknowledged potential concerns about the time it takes to implement such measures; indeed, she herself once held those very reservations. But she has found that using PROMs actually helps consultations to be more efficient, in that patients’ concerns are identified before the GP sees them.

‘The classic thing for general practice is that you spend a whole heap of time chatting to your patients, then you’re finishing up and you’re about to show the person out and they put their hand on the door and say, “Oh, by the way, doc,” Dr Wilson said.

‘Quite often, that turns out to be the important thing. And how fantastic would it be if you’d been able to get to that sooner?

‘It’s not that we’re not good at our jobs and we don’t get to that point earlier; there’s a whole heap of factors that get in the way. But these measures can actually assist to get the important stuff out faster.’

Dr Wilson believes that, despite the challenges it may present, implementing both PREMs and PROMs into the patient feedback process is well worth the effort, and she hopes the ACI project is helpful in assisting general practices to do so.

‘It’s good stuff,’ she said. ‘[PRMs] can save us time and help us to get to what’s important. It can actually assist your therapeutic alliance because you are getting to what’s important faster.

‘And it can make sure that you know how you are doing with patients over time.’

 

Reference

1. Goodwin N, Dixon A, Poole T, Raleigh V. Improving the Quality of Care in General Practice: Report of an independent inquiry commissioned by The King’s Fund. London, UK: The King’s Fund, 2011.