Measuring Client Satisfaction
By Carol M. Frattali
The following article was originally published by ASHA in the Winter 1991 Quality Improvement Digest.
Few clinicians would debate that clients are the central focus of both service delivery and quality measurement. Yet, the client's perspective on quality care largely has been considered external to the service delivery process (Weisman & Koch, 1989). In recent years, client satisfaction with clinical services has gained recognition as an outcome of quality care. Donabedian (1988), a noted authority in quality measurement, states:
Patient satisfaction may be considered to be one of the desired outcomes of care, even an element in health status itself…It is futile to argue about the validity of patient satisfaction as a measure of quality. Whatever its strengths and limitations as an indicator of quality, information about patient satisfaction should be as indispensable to assessments of quality as to the design and management of health care systems (p. 1743).
Weisman and Koch (1989) have indicated that satisfied clients are more likely to follow their practitioners' recommendations for treatment. Furthermore, research has shown that client satisfaction (or dissatisfaction) is an indicator of other client behaviors, such as choice of practitioners or programs, disenrollment, use of services, complaints, and malpractice suits (Ware, 1987). Weisman and Koch believe that tools designed to elicit client feedback often are the only channel through which clients can alert providers to their concerns, needs, and perceptions of treatment. "Patient feedback is especially important to the QA [quality assurance] process because it helps health care providers identify potential areas for improvement, such as patient education and follow-up, specific quality of care issues, and hospital procedures (e.g., reimbursement policies, the admissions process). It is also useful in program planning and evaluation" (p. 167).
Client Satisfaction: An Operational Definition
Client satisfaction is a multidimensional concept, relating to both technical and interpersonal aspects of care, and the amenities of care (such as an attractive physical environment, and convenient location and parking). Donabedian (1980) points out that a client's assessment of quality, expressed as satisfaction or dissatisfaction, could be remarkably detailed. "It could pertain to the settings and amenities of care, to aspects of technical management, to features of interpersonal care, and to the physiological, physical, psychological or social consequences of care. A subjective summing up and balancing of these detailed judgments would represent overall satisfaction" (p. 25).
Davis and Hobbs (1989), healthcare administrators who designed an outpatient satisfaction measure for the Rehabilitation Services Department of University Hospital—University of British Columbia, define client satisfaction as the extent to which a program fulfills clients' treatment expectations. Davis and Hobbs have identified the various components of client satisfaction to allow an accurate measurement. These components were classified into three dimensions of satisfaction:
- Access to Care (e.g., signs and direction to treatment facility, waiting room time, clinic hours);
- Physical Environment (e.g., cleanliness of reception area, noise level, and condition of treatment space); and
- Care Received (i.e., human, clinical, and outcome aspects).
Davis and Hobbs (1989) used this operational definition to devise a conceptual framework from which to design a client satisfaction questionnaire.
Client Perceptions of Quality Care
Clinicians' and clients' views about quality of care can differ vastly. While clinicians are known to define quality primarily by their technical skill, clients are inclined to define quality by a clinician's interpersonal skills. An illustration of these divergent perceptions of quality care is found in a recent article and subsequent letter-to-theeditor in Asha. Dorothea Wender (1990), an individual with aphasia who underwent a course of language treatment, wrote an article titled: "Quality: A Personal Perspective." She describes a "good therapist" and a "bad therapist." The good therapist was perceived as a person who respected her, treated her as an intelligent adult, smiled often, and talked with her daughters. The bad therapist was perceived as business-like, didactic, insensitive to the use of childlike clinical materials, and rigid in treatment style. Not surprisingly, her article prompted letters to the editor from the "bad therapist's" peers. Says one colleague:
The person described as a "bad therapist" was actually an outstanding aphasiologist…If the reader only knew that the speech-language pathologist is so highly regarded, the article would have been so much more useful (Asha, May 1990, p. 3).
Although the importance of technical over interpersonal care can be convincingly argued by clinicians, client perceptions about quality cannot be ignored. Superior technical care may not be effective in the absence of a good interpersonal relationship. Poor interpersonal skills often involve poor communication with the client, which can lead to client dissatisfaction. For example, the client may not understand the rationale for a particular procedure, or may be unaware of potential consequences. Such dissatisfaction can be prevented through appropriate client education. Interpersonal aspects of care that include clear communications and informed consent for specific procedures is therefore recommended to not only educate the client, but to protect both the client and practitioner in cases of litigation.
According to Harper Petersen (1989), the following aspects of care are found in the professional literature as significant components of client expectations:
- Being comfortable;
- Being treated as a mature individual;
- Getting information about what will happen;
- Learning how to participate in care;
- Feeling safe;
- Needing reassurance;
- Feeling more in control;
- Decreasing stress; and
- Having staff available to listen.
In summary, both interpersonal and technical aspects of care must be considered when measuring quality. Anecdotal evidence affirms that acceptable care contributes to client cooperation and, thus, to successful outcomes (Palmer & Reilly, 1979). However, little is known empirically about what specific interpersonal qualities positively affect clinical outcomes. Reliable and valid client satisfaction measures can be used to effectively explore this relationship.
How and When to Measure Client Satisfaction
Various methods can be used to measure client satisfaction. While a self-administered questionnaire is the most common and systematic method, other methods include focus groups, informal visits with clients by support staff or other clinical staff, client suggestion boxes, and client hotlines (Harper Petersen, 1989).
Recognizing the importance of eliciting client feedback during the clinical process, the American Speech-Language-Hearing Association's (ASHA's) Committee on Quality Assurance designed a client satisfaction measure for ASHA members and other interested professionals. The measurewas a one-page mailable questionnaire for obtaining feedback from clients or their family member/caregiver about the quality of speech-language pathology and audiology services (see Figure 2). ASHA's Consumer Satisfaction Measure (1989) consisted of three parts: the questionnaire, directions for completion, and a detachable follow-up reminder card. The measure addressed degree of client satisfaction with timeliness of service, interactions with staff, service outcome and physical setting. A second measure, which was an adaptation of the original, was used to obtain client feedback for multidisciplinary rehabilitation services (including physical therapy and occupational therapy). ASHA's measure was derived from a review of available client satisfaction measures and the current professional literature, consultation with ASHA's Consumer Advisory Task Force, and extensive peer review. Although the tool was developed to have applicability across work settings, the tool was best suited for use in clinics, hospitals, and other facility type settings.
Once a data collection method is selected, the time schedule for data collection must be determined. Most surveys of client satisfaction are conducted after care has been provided. However, Harper Peterson (1989) indicates that the interaction between clinician and client can be used to solicit feedback while the client is still receiving care. Such ‘concurrent' review is necessary to ensure that the client's and clinician's goals remain congruent, and to maximize client cooperation during the course of intervention.
Using Client Feedback Effectively
The effective use of client feedback requires a formalized method of response. Harper Petersen (1989) recommends the formation of a representative group of staff members charged with reviewing and following up on all client satisfaction data. First, staff should anticipate and minimize client complaints by identifying staff/program weaknesses in areas of concern to clients. Spitzer (1988) summarizes such concerns after reviewing recent studies:
- Staff were uninvolved and dehumanizing;
- Staff distanced themselves from clients;
- Staff did not involve clients in decision making;
- Staff focused on the procedure, rather than on the client;
- Staff showed a lack of empathy or openness to clients' feelings; and
- Staff discussed the client in his/her presence with another professional(s).
Next, staff can analyze both quantitative and qualitative data. When qualitative comments are made by clients, selected members of the group could perform a content analysis from feedback obtained from open-ended questions. Miles and Huberman (1984), in their text on qualitative data analysis, believe that the client's own words render more meaning than numbers alone. Practitioners often find qualitative data more gratifying when clients are satisfied, and more motivating for change when clients are dissatisfied.
Once the data are analyzed, staff should identify opportunities for improvement, and chart a plan of action aimed at continually improving the level of client satisfaction with services rendered.
Clinicians are increasingly taking an interest in what clients have to say about the quality of their care. As a result, client satisfaction is gaining recognition as a legitimate indicator of treatment outcomes (Nelson, Hays, Larson, & Batalden, 1989). An expert panel convened by the federal Office of Technology Assessment (1988) recently defined quality clinical outcomes to include measures of changes in patient health status and satisfaction. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (1989), in its principles of organization and management, notes that a program that supports and promotes continuous improvement in the quality of care is one that seeks feedback on the quality of care from patients as well as practitioners.
In federal regulation, a client oriented approach to health care delivery is becoming a trend. The most recent example is found in the new nursing home regulations. These regulations require the participation of nursing facility residents in the development of comprehensive care plans:
(2) A comprehensive care plan must be—
(ii) Prepared by an interdisciplinary team, that effective October 1, 1990, includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and with the participation of the resident, the resident's family or legal representative, [emphasis added] to the extend practicable…[42 Code of Federal Regulations, Part 483,20 (d)]
From a business and marketing perspective, client satisfaction takes on added import. In such a competitive marketplace, a happy customer leads to an increased market share. Weisman and Koch (1989) aptly conclude:
It stands to reason, then, that providers who actively seek and respond to patient opinion will enjoy not only healthier and more satisfied patients, but a more favorable position in today's competitive health care marketplace. Clearly, good quality is good business (p. 167).
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Davis, D., & Hobbs, G. (1989, June). Measuring outpatient satisfaction with rehabilitation services. Quality Review Bulletin, 15, 192–197.
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Joint Commission on Accreditation of Healthcare Organizations. (1989, April). Principles of organization and management effectiveness. Unpublished Report. Chicago, IL: Joint Commission Organization and Management Task Force.
Nelson, E. C., Hays, R. D., Larson, C., & Batalden, P. B. (1989, June). The patient judgment system: Reliability and validity. Quality Review Bulletin, 15, 185–191.
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Weisman, E., & Koch, J. (1989, June). Progress notes: Special patient satisfaction issue. Quality Review Bulletin, 15, 166–167.
Wender, D. (1990, January). Quality: A personal perspective. Asha, 32, 41– 44.