Skip to main content

Table 1 Methodological characteristics and main findings

From: Patient feedback to improve quality of patient-centred care in public hospitals: a systematic review of the evidence

First author (year); Country; Setting Interventions Study characteristics; design; method; data source Participants’ characteristics Main results Quality Assessment
RCT studies
 Reeves (2013) [35]; UK; 2 NHS Trusts The interventions for 3 groups:
1) Control group: CQC survey results given to Director of Nursing.
2) Basic feedback group: Individual letters with detailed ward-level CQC survey, results sent to nurses and their matrons.
3) Feedback Plus group: Same as Basic feedback group with the addition of ward meetings with study researchers to discuss CQC survey results and plan improvements in practice.
‘Pilot study’ for cluster RCT; NHS Care Quality Commission (CQC’s) Inpatient Questionnaire-subset nursing care with 20 questions scores ranged between 0 to 100. 4236/9565 patients surveyed across 18 wards (47% response rate). The 3 groups consisted of 6 wards, (No. of nurses in the wards were not reported) The mean score was 75.4 at baseline. Feedback Plus wards experienced an improvement in scores the difference between Control and Feedback Plus wards is 8.28 ± 7.2 (p = 0.02). There is no evidence that Basic feedback group lead to improved patient experiences, or that nurse pay attention to results when they are in printed form. Medium
Before-After Studies/ Cross-sectional Studies
 Harnett (2010) [36]; US; 1 hospital (Pre-operative clinic) The interventions were:
1) Provide anaesthesia education programme to Nurse Practitioners and after the training, all assessments for a single patient was conducted by a Nurse practitioner with laboratory technician conducting tests in the same room at the same visit.
2) Change in Nurse Practitioner shifts from 8 to 10 h to improve room utilisation.
3) Blank appointment slots were left for surgical add-ons instead of disrupting already scheduled patients.
4) Postcard appointment reminder sent to patients in advance.
5) 2 h weekly staff meetings for clinical and non-clinical staff on customer service, patient relations, and teamwork.
Before – after study; study specific 14- item questionnaire (Likert scale 1–5) consisting of satisfaction with clinical providers and with organisational aspects of clinic visit was administered to different patients who attended the preoperative clinic at two time periods (March 2005 and March 2006). 872/1100 patients responded (79% response rate), with 443 patients in cycle 1 and 429 patients in cycle 2. The questionnaire scores for 3 out of 14 items showed significant improvement (P ≤ 0.01) The 3 items related to the explanation of the preoperative clinic by the surgeon’s office, courtesy and efficiency of the clinic staff and satisfaction with the amount of waiting time. The average waiting times reduced from 92 ± 10 mins to 42 ± 5 mins. Medium
 Aboumatar (2015) [37]; US; 52 Hospitals No intervention Before - after study; hospital performance in the HCAHP survey was extracted from the publicly available December 2012 HCAHP report; study specific online survey of a set of 12 binary response questions and 3 open-ended questions were emailed to participants who were nominated by their hospital CEOs. 52/169 hospitals recruited based on the study’s high-performance criteria for at least 1 HCAHPS domain; 138 respondents from 52 hospitals participated in the survey. High performing hospitals reported use of interventions on both the patient and system levels.
Patient level interventions
1) Improve responsiveness to patient; 83% used proactive nursing round; 62% used executive/leader rounds.
2) Discharge experience; 56% used multidisciplinary rounds; 54% used post discharged calls; 52% used discharge folders.
3) Patient-clinician interactions; 65% promoted specific desired behaviours; 60% set behavioural standards where employees were held accountable.
4) Engage and educate employees (71%) and leaders (83%) about the behaviours needed to ensure positive patient experiences.
5) Hospital leaders monitored and audited desired behaviours to hold employees accountable (50%).
 Buurman (2016) [38]; The Netherlands; 1 hospital The implementations were:
1) Education of interns, residents, staff.
2) Medical interns given targets to issue PPDL.
3) Standardised content & templates.
4) Integrating PPDL into electronic medical record.
5) Integrating PPDL into hospital wide policy.
Before – after study; structured telephone interviews with patients, 1 week after discharge was conducted by a research nurse; focus group conducted with nurses and physicians on the use of personalised patient discharge letter (PPDL) in daily practice. 141 patients participated in this study. 111 patients participated in the pre-implementation phase and 30 patients in the post implementation phase. Participants for focus groups (not reported). Patient satisfaction with the PPDL was 7.3 out of 10. The level of implementation increased from 30 to 51% because of incorporating the PPDL into the electronic patient record (EPR) and professional education. Low
 Kleefstra (2016) [39]; The Netherlands; 10 health inspectors Provide negative patient reviews on hospital rating sites on a hospital that was supervised by the health inspector (participant) Before-after study; Semi-structured interviews were conducted with the participants, subsequently negative patient reviews on hospital rating sites and the hospital contextual details were emailed to the participants and they were interviewed again 4–6 months later. 10 Senior Health inspectors 23% of patient reviews were deemed relevant for risk identification by the senior health inspectors. The reviews which included major safety problems, severe damage or consequences for the patient and structural organisation problems, malfunction of doctor was deemed relevant. Low
 Ancarani (2009) [40]; Italy; 7 hospitals No intervention Cross-sectional study; study specific organisational climate survey was administered once to all medical staff and the SERVQUAL instrument measuring patient satisfaction was administered once to all patients in 47 wards in 7 public hospitals. All members of the medical staff and consecutive patients prior to discharge were also interviewed. 625 Healthcare professionals (470 nurses and 155 physicians) and 1018 patients participate in the study. Organisational model stressing openness, change and innovation and organisational model emphasizing cohesion and workers’ morale are positively related to patient satisfaction, while a model based on managerial control is negatively associated with patient satisfaction. Medium
 Richard (2010) [41]; Canada; 1 hospital cancer centre No intervention Cross-sectional study; study specific survey using 21 items from a Canadian validated question bank measuring patient satisfaction was administered over 1-month period to ambulatory cancer patients. 276/575 patients responded (48% response rate). It was reported that wait times and telephone contact with healthcare providers were the 2 areas of lowest satisfaction. 72.5% (n = 103) of patients followed by a nurse navigator; were satisfied with the length of time spent in the waiting room compared with 66.2% for patients without a nurse navigator (n = 77). Low
 Madden (2010) [42]; UK; NHS trusts No intervention Secondary data analysis from two national surveys of patient experiences in 2000 and 2004 and Thames Cancer Registry. The respondents from the national surveys of patient experience were surveyed at different times after discharge and a year elapse between data collection and reporting. The cancer registry contains area registration of patients in South East England, their diagnosis and clinical information from hospitals. 69,660 patients responded; 65,337/88293 patients from 172 hospital trusts responded (74% response rate) in year 2000 and 4323/7860 patients from 49 hospital trusts responded (55% response rate) in year 2004. Comparison between 2000 and 2004 surveys showed some overall national improvements in areas of information, communication and trust in health professionals. Only breast cancer patients from 3 health trusts were compared due to data availability and there is a significant decline in 2 areas; ‘ease of understanding of tests from doctors’ and ‘feeling confidence in the doctor at the last outpatient appointment’. Low
Case Studies and participatory action studies
 Reeves (2008) [43]; UK; 24 NHS trusts No intervention Case series; semi-structured interviews using interview guide specific to the study was conducted with patient survey leads from 24 NHS trusts. 24 patient survey leads who held varied positions such as Director of Nursing, Director of Patient and Public Involvement, Quality Development Manager and Head of Clinical Governance were interviewed. Actions implemented for quality improvement were:
1) Action plans aimed at improving the quality of care and for measuring the success of those plans.
2) Implementation of action plans was now part of some individuals’ performance assessment.
3) Asking patients to keep records of the source of disturbing noises.
4) Floor coverings were changed, quieter waste bins.
5) were installed, and, where possible, patients admitted overnight were put into a separate area.
6) produced comprehensive discharge information packs, which were given to patients on admission.
Barriers identified:
1) Difficulty engaging clinicians because survey findings were not sufficiently specific to specialties, departments or wards.
2) Culture of the organisation.
3) Lack of knowledge of effective interventions.
4) Lack of statistical expertise.
5) Limited time and resources.
 Long (2008) [44]; Australia; 1 hospital No intervention Case study; study reported a four-phase methodology; Phase 1, the conduct of discovery interviews to identify and develop quality improvement strategies; Phase 2, strategies were sent back to the same participants for validation; Phase 3, focus group conducted with clinicians and quality managers to validate the quality improvement strategies identified and phase 4 integrating the improvement strategies with the hospital’s quality improvement programme. 30 patients who has experience an adverse event and six quality managers and clinicians. The improvement areas identified and validated are in communication with consumers, consumers education,
assessment and prevention of adverse events and clinical environment contributing to the occurrence of adverse events.
 Hsieh (2010) [45]; Taiwan; 1 Teaching hospital No intervention Case study; study specific critical incident questionnaire was employed for all complainants over 3 months by hospital social workers trained in critical incident technique and non-participant observation of the hospital was conducted over a-3-month period by researcher. 59 complainants completed the critical incident questionnaire. The most common themes identified for cause of complaints were care/treatment, humaneness and communication.
The study found that of 149 resolutions, 105 taken by the hospital involved an explanation of the facts to complainants (n = 41), investigation of events (n = 33) and empathy with complainants (n = 31). The lack of any systematic use of complaints data was reported as a failure for the hospital.
 Latta (2010) [46]; Australia;1 Health service with 7 public and private hospitals. No intervention Case study (No details reported) None reported Reported the implementation of integrated case management and care pathway had led to improved risk management, reduced lengths of stays, healthcare costs, and increased patient and staff satisfaction. Low
 Schneider (2010) [47]; South Africa; 1 public hospital No intervention Case study; observations and informal conversations with patients and staff in emergency department, admission ward and medical wards were conducted. Interviews were conducted with 30 staff and on the spot, surveys conducted with 41 patients while they are waiting in the emergency department and 2 focus groups conducted. 71 participants consisted of 30 hospital staff and 41 patients. Focus groups participants (not reported). It was reported that patient’s actions were oriented to two main goals: obtaining care and preserving their sense of self and dignity. Medium
 Davies (2011) [48]; US; Veterans hospitals No intervention Case study; selection of hospitals was based on their stable high or low scores on the dimension of emotional support derived from the Survey of Healthcare Experiences of Patients (SHEP) conducted from 2002 to 2006; semi-structured interviews was conducted by telephone with respondents at work. 8 healthcare professionals consisted of 2, executive directors, 2 patient advocates, 2 customer service managers 1 ward nurse and 1 advanced nurse practitioner from 2 Veterans hospital were interviewed in the study. Promoters of quality improvements found:
1) Developing patient-centred cultures
2) quality improvement structures such as regular data review
3) Training staff in patient-centred behaviours.
4) The influence of incentives
5) The role of
6) nursing leadership
7) Triangulating survey data with other data on patients’ views
Barriers of quality improvements found:
1) Clinical Scepticisms
2) Defensiveness and resistance to change
3) Lack of staff selection, training or support
4) Lack of timely feedback
5) Lack of specificity and discrimination of survey results
6) Uncertainty about effective interventions
 Hsieh (2011) [49]; Taiwan; 1 hospital No intervention Case study; semi-structured interviews were conducted with hospital staff, government staff and non-government staff. Administered semi-structured study specific questionnaires for hospital staff and review of documentation of activities in the hospital. A separate study specific critical incident questionnaire was employed for all complainants over 3 months and non-participant observation of the hospital was conducted over a 3-month period. 123 participants consisted of 4 key managers and social workers, 4 government staff, 3 non-government staff, 53/72 respondents to the questionnaire (73.6% response rate) and 59 complainants completed the critical incident questionnaire. This study revealed that the hospital attempted to resolve complaints on a case-by-case basis. It did not act on these complaints as a collective group to identify systemic problems and deficiencies. Medium
 Piper (2012) [50]; Australia; 7 hospitals Experience-based co-design (EBCD) programme using a five-phase methodology within 43 to 44.5 weeks’ timeframe. Case study; selection of 7 hospitals based on their previous participation in the EBCD programme. Documentation from the EBCD programme provided by the 7 hospital and semi-structured interviews with staff and consumers. 117 participants consisted of 3 department staff, 59 frontline staff & management, 41 project staff and 26 consumers. EBCD were used in improvement areas of:
1) Patient and carer comfort
2) Physical spaces
3) Respect and courtesy, information for patients and patient perceptions
It was reported to have improve operational efficacy and inter-person dynamics of care.
Main barriers to the use of EBCD identified were:
1) Sustaining consumer engagement from ambulant population in emergency departments.
2) Tailoring to consumer preferences & constraints.
3) Perceived as separate & additional task.
 Tsianakas (2012) [51, 52]; UK; 1 Cancer centre Experience-based co-design project over 12 months Participatory action research; fieldwork involved 36 filmed narrative patient interviews, 219 h of participant observation of clinical areas along the patient pathway and 63 staff interviews and facilitated a co-design change process with patient and staff participants. 4 staff and 5 patients were interviewed again about their views on the value of the approach and its key characteristics. 99 participants consisted of 36 (23 breast and 13 lung cancer) patients and 63 staff. It was reported patients living with breast and lung cancer identified similar issues in receiving diagnosis, continuity of care, communications between staff and patients, appointments process and inpatient experience that shaped their experience. High
 McDowell (2013) [53]; UK; 3 NHS Trusts No intervention Case study None reported Described the implementation of an engagement model of both patients and staff encourages ownership and co-creation of solutions. Low
 Abuhejleh (2016) [54]; UAE; 1 Hospital Use of Lean six sigma methodology and
Kaizen Plan-Do-Check-Act cycles
Case study; interviews were conducted
in the hospital and the information collected
from the interviewees was reviewed and verified by a LEAN project leader at the hospital.
No details reported The innovation projects reported decreased in patient access and waiting time, improved safety and patient satisfaction and supported the hospital culture of empowering front-line caregivers. Low
 Blackwell (2017) [55]; UK; 1 Hospital Experience-based co-design project over 19 months. Participatory action research;150 h of non-participant observations, semi-structured interviews with 15 staff members about their experiences of palliative care delivery, 5 focus groups with 64 staff members to explore challenges in delivering palliative care, 10 filmed semi-structured interviews with palliative care patients or their family members and 1 co-design event with staff, patients and family members. 93 participants consisted of 79 staff, 10 patients & caregivers and 14 staff, patients and facilitators. The study identified quality improvement priorities leading to changes in Emergency Department-palliative care processes. It also led to the creation of a patient-family-staff experience training DVD to encourage application of generic design principles for improving palliative care in the emergency department. High