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Consumer Engagement Part 2 Print E-mail
The Quarterly 2012

This article was written by Dr Susan Keam, derived from material presented by Ms Deborah Smith and Dr Lee Gruner on Thursday the 22nd of March 2012 for the RACMA Interact Webinar series.

This article considers the reasons for and benefits of consumer engagement in health care delivery. In part 1, Deborah Smith of the Consumers Health Forum of Australia identifies the significant benefits that consumer engagement contributes to clinical quality and health outcomes, the experience of care, and the business and operations of delivering care. She also discusses the way in which frameworks are used to assess how well engagement is happening across an organisation. In part 2, Dr Lee Gruner discusses the five enduring service factors that consumers look for in health services, and then considers the beneficial effects of consumer partnerships on the efficiency, effectiveness, quality and reputation of health services, as well as the role of consumer partnerships as a driver for implementing the new accreditation standards (National Standards Partnering with Consumers - Std 2).


Part 2: Meaningful Consumer Engagement in Health Care: Working With Consumers to Improve Health Services

Dr Lee GrunerDr Gruner's interest in consumer engagement has grown out of her experience of working in the Heidelberg Repatriation Hospital (repatriation hospitals with a consumer focused service and a strong emphasis on patient-centred care were run by the Commonwealth for war veterans); in introducing structured consumer involvement in the private psychiatric sector at the Melbourne Clinic, at the ACHS and from interviewing health service consumers in her current role.

Consumer Service Factors
Consumers of health services today still want pretty much the same things they have always wanted: good communication, empathy, treatment as an individual. Likewise the things that continue to annoy them are long waiting times and poor or problematic facilities and sub standard equipment.

Research over many years has shown consistently that there are five factors that consumers look for in general and these apply equally to health services:
  • Reliability: providing what is expected, on time
  • Empathy: courtesy, kindness, consideration and warmth
  • Responsiveness: personalised service, willingness, anticipation of needs and response to needs
  • Tangibles: good facilities, cleanliness and a good standard of food
  • Assurance: competence, credibility, safety, dependability and a good reputation
While we recognise that these are important factors, we generally don't do a lot with them. We also know that some of these factors are more important to consumers than others. These include both tangibles (facilities, cleanliness and food quality) that are easily judged by consumers, and intangibles - consumers are also very aware of whether hospitals are dependable, credible and safe, and they are always looking for courtesy, kindness and consideration. Reliability (or lack of it) is often a dissatisfier, because the services we provide are not always as reliable as we would like.

Usually we use these consumer service factors in a reactive way, after the event and as part of patient feedback (as a structured tool or patient complaints). However, it’s more useful to use them in a proactive way when developing strategies and planning, when reviewing policies, procedures and patient information and when looking to improve services and service delivery. Understanding consumer service factors helps us as service providers to foster active participation for consumers that is both valuable to the health service and valued by the consumers themselves. On a more practical note, we also need to remember that partnering with consumers is a mandatory standard for national accreditation and proactive approaches need to be developed to meet this.

Consumer research
While some of the best research around consumer service needs in health is quite old (Refer to the US survey conducted 20 years ago, documented in a book "Through the Patient's Eyes"), the conclusions are still relevant today, because when we talk to consumers we hear that the things they do and don't want haven’t changed a lot.

What the studies say:
Research results can be grouped around the five customer service factors mentioned earlier.

Reliability
People want an explanation of waiting times, an understanding of what to expect in pain and anaesthesia and they want all staff to convey the same message. They also get upset if what is promised is not delivered.

Empathy
People want respect from staff, involvement in decision making, provision of problem solving /counselling, involvement of carers/ family and as much information as possible.

Responsiveness
People want care givers to be available and attentive to their needs, they want acute pain to be managed appropriately and they want assistance with simple physical needs. They are appreciative of extra efforts to make them comfortable, but a slow response to a nurse call is a major dissatisfier.

Tangibles
Patients are very aware of cleanliness (or lack of it) and are also aware of facilities in need of renovation. They want attention to flowers, and they want the air conditioning to work correctly.

Assurance
People want consistent, knowledgeable staff, a clean, quiet, well run hospital, well coordinated care/ good communication between staff groups, an understanding of processes of care and good discharge planning with arrangements conveyed to family members.

What patients say:
Patients say that they want information such as who the staff are and what is going to happen. They want to know what to expect, including honesty about unpleasant procedures and pain. They need to know about their illness and they want to know about anaesthesia and what to do when they get home. Importantly, they feel very helpless and disempowered.

The most important needs of patients are acute pain management, kindness, attention to basic needs (high dissatisfaction if these are not attended to) responsiveness and courtesy to themselves and visitors (visitors are future customers). Major dissatisfiers include extended waiting times, lack of personal and individual attention, lack of explanation and communication, an environment in need of renovation and lack of cleanliness. Areas for improvement patients’ talk about are treating the patient as an individual, introduction to staff members, recognition of patient opinions, informing family and friends and the amount and quality of information given.

What patients notice:
In an environment where they feel helpless and disempowered, patients notice empathy (associated with better recall of advice and more satisfaction), cleanliness, how the system works and faults in the system (when shared with the service provider, this can help to make huge changes in efficiency and effectiveness). They are aware of tasks not done (patients do not distinguish staff demarcations relating to work), and anything that happens in and around their rooms. This impacts on privacy and the importance of staff being careful in what they say and do.

A survey of 17,000 patients in British Columbia Emergency Departments conducted in 2007 by Diane Watson et al. found that from a patient perspective, the biggest impact on quality was staff courtesy. Other factors that contributed to quality (in decreasing order of importance) were teamwork between doctors and nurses, comprehensiveness of services and availability of nurses. The most important negative perception of quality was the time to see a doctor.

Using consumer service factors to involve consumers: linking research with the new Accreditation Standards
The Intention of the National Standards Partnering with Consumers - Standard 2 is to create a health service that is responsive to patient, carer and consumer inputs and needs. The standard encompasses consumer partnerships in:
  • Service planning: governance structures to facilitate partnerships, processes for involvement in planning, safety and quality initiatives, quality improvement activities, training for consumers, involvement in patient information provided to consumers
  • Designing care: delivering care to meet patient needs and experiences, education of senior staff in how to engage consumers
  • Measurement and evaluation: providing data on safety and quality, involving consumers in analysis and implementing actions, involving consumers in evaluation of feedback and developing actions
We can expand on each of these factors by identifying ways in which they can be implemented to improve health service provision.

Consumer partnership in service planning
  • Governance: determine what process will work best for involving consumers in governance of the organisation and how to effectively recruit consumers
  • Policies and procedures: develop and implement appropriate mechanisms to partner with consumers in planning, safety and quality and quality improvement activities
  • Educate consumers so that they can contribute effectively
  • Patient information - ensure this meets consumer needs by testing with consumers Active participation of consumers will impact on reliability, assurance and tangibles and start to make a difference in delivering the things people need
Consumer partnership in designing care
  • Care delivered to meet needs of consumers requires active participation of consumers in care design and re-design
  • Training for senior staff fosters understanding of value of consumer engagement and ways to enhance this. Consumers can be used in the training
  • Active participation will impact on all of the consumer service factors as consumers will bring their experiences and knowledge to discussions and enhance decisions on care options
  • Consumers can be a very powerful voice in influencing clinicians
Consumer partnership in service measurement and evaluation
  • Information provided on safety and quality performance: requires discussing with consumers what their needs are
  • Participation in analysis of data and action plans requires a process to ensure the analysis is meaningful and consumers can contribute to this and ways to evaluate any actions
  • Participation in the evaluation of feedback data and action plans related to this requires a forum for discussion and evaluation of action
  • These mechanisms provide consumers with an understanding of up to date health service performance as well as consumer experiences and perceptions
Meaningful consumer participation will continue to be a challenge. It’s not easy to get the right consumers, or sometimes any consumers, willing to commit to participation. Even when we do manage to get appropriate consumers recruited, they can be too overwhelmed to contribute. We also need to keep in mind that appointed consumers may have vested interests, and consumers who stay with a health service too long may become part of the organisation, rather than truly representing the consumer. In addition to these consumer-related issues, there are some organisational issues. For instance, the organisation may be unsure as to how to best use consumers and clinical staff can often be patronising to consumers instead of considering consumer opinions to be of value as they give a different perspective.

Successful consumer participation depends on a number of factors, including thoughtful recruiting, appropriate peer support, effective education and training of consumers and staff and visible application of thoughts and ideas from consumers.

Take the time to recruit consumers who provide a diverse range of inputs (different strata of society, from different perspectives so that they can bring different experiences to the committee). Educate and support consumers in their role and educate staff on the value of the consumer voice and how to work with consumers and chairs of committees on actively seeking consumer input if they don’t speak up. Provide practical peer support by having at least two consumers on committees or QI activities, as this will make them feel that they are more able to communicate. Act on consumer input and feedback making consumer participants feel valued. Actively benchmark with other organisations to discover better ways of involving your consumer representatives.

Having to implement the National Standards may be the driver for establishing consumer partnerships in many organisations, but if organisations can see beyond this ‘tick box’ application, then major benefits, such as:
  • Enhanced efficiency and effectiveness of service delivery (identify things consumers do/don’t want, do/don’t need)
  • Better quality health service
  • Improved patient safety
  • Enhanced reputation resulting from greater consumer focus
  • Cost savings resulting from fewer complaints, not providing services patients do not need, fewer medico-legal cases, more rapid implementation of change will be achieved with active consumer participation.
Dr Lee Gruner FRACMA
Director of Quality Directions Australia Pty Ltd