What is it and how can it help me?
There is no one right way of collecting patients’ views; different methods suit different purposes. However, it is important that you use a method appropriate to the group of patients involved, and the planned service improvement. This guide describes four different methods of obtaining patient perspectives: questionnaires, focus groups, semi structured interviews and patient shadowing.
When does it work best?
Each method works well in a different situation. This is outlined with each tool.
It is often those closest to the process who are best placed to give useful feedback on the way services work and how they can be improved. As patients are the ones who experience the process or service first hand, they have a unique, highly relevant perspective. Their input into designing services can be invaluable as they have an experience that staff can’t access. Sometimes, seeing services from the patients’ point of view opens up real opportunities for improvement that may not have been considered before. This may include changes that make life easier for staff and patients, whilst reducing delays at the same time.
Some general rules
- Always have clear objectives: what are you trying to achieve?
- Plan what you are going to do
- What is the scope of the project? Decide upon any boundaries
- Don’t ask for input if you have no intention of making changes - tokenism is easy to spot and offensive to many.
The four methods
A questionnaire is a straightforward way of getting information from lots of people. Easy to administer, they can capture the perceptions and experiences of patients, users, and carers. You can also use them to measure levels of satisfaction with a process or service.
When to use it
Questionnaires are useful for measuring baseline information and to evaluate change over time.
- Be clear about what you are trying to accomplish, what you want the information for and how you will use the results
- Involve patients and service users in devising questions
- Structure questions carefully: consider the balance between multiple choice (yes/no or Likert scale) and free text questions. Multiple choice questions are quicker for the user to complete and for you to analyse. Free text questions often provide more valuable data if completed, but take longer to analyse
- Keep it short: it should take no more than 10 minutes to complete
- Always pilot the questionnaire: using small tests of change is a useful way to refine and improve questions
- Decide whether the questionnaire will be anonymous or not
- Think about how you will reach your target group. Leaving questionnaires in waiting rooms, day rooms or handing them out at reception is a good way to reach patients and carers. Remember to provide pens. If posting, include a freepost or SAE for returns
- Snap shot audits are a good way to get a representative sample of views from patients using a specific service. This is a short questionnaire given to every patient who attends a particular clinic on a particular day, or over a particular week.
2. Focus groups
A focus group is an informal collection of people sharing common characteristics. They meet to discuss and debate their experiences about a specific topic or problem e.g. patients who have recently visited the accident and emergency department. Focus groups will usually meet on one occasion only.
When to use it
This is a useful way to listen to a wide range of experiences about a single area.
- Establish how you will fund expenses before setting up the group
- Clarify the purpose, objectives and timings of the group
- Send an invitation letter explaining the process, what is expected of the patients and what the expected outcomes are
- Groups should comprise of 6-12 people
- The focus group should last between one and two hours
- Make sure the venue is accessible to all participants
- Agree ground rules and an agenda for the group
- Use prepared questions and themes relating to the topic for discussion
- Have a good facilitator who will not seek to lead but has strategies to help the group if they get stuck
- Provide refreshments
- Feedback outcomes / progress to the group
3. Semi structured patient interviews
Semi structured one to one interviews are used to collect qualitative data. They aim to understand the respondent’s point of view rather than make generalisations. The interviewer can delve more deeply and ask why. This often yields more information and emotional response than a questionnaire. The patient also has the opportunity to ask for clarification. They are however, more time consuming to conduct and analyse.
When to use it
When you want a patient to tell you about their most significant needs. This technique also generates improvement ideas that can be tested out in practice.
- Gain each person’s consent; guarantee confidentiality and anonymity
- Use open ended questions. Some will be planned (‘Tell me about…’) and some will arise naturally during the interview (‘You said a moment ago ..’, ‘Can you tell me more...?')
- Clarify what is being said so there are no misunderstandings
- Aim for a conversational feel: questions should be asked when it feels appropriate; they may be planned or spontaneous
- The wording of the questions may vary in different interviews
- Consider using an interviewer who is external to the topic being discussed e.g. from another department or an external organisation
- Keep the number of interviews manageable; many improvement ideas can come from just a few interviews.
4. Patient shadowing
This is when a member of staff or volunteer accompanies the patient on their journey through the health system. Preferably, the shadower will be unfamiliar with the process and should also be comfortable asking 'why?’ This is a similar approach to a .
It provides objective, observational feedback that needs to be balanced by other approaches, for example, by obtaining the views of the staff providing the service. Using this technique, you can record patient movement in time and space as well as capturing perceptions of the service. This enables you to build up a comprehensive picture of movement, combined with a flow diagram of actions and a qualitative perception of the process. While the patient is being shadowed, their shadower can use interview techniques and observation to supplement the information provided by the patient.
When to use it
By mapping a patient process, you can find out what really happens on the patient’s journey. This also helps to monitor and measure service performance.
This technique is also useful as a training and development tool to help staff understand what is important to patients.
- Establish what you are trying to achieve and how shadowing will help you achieve it
- Clarify why this process is appropriate and what aspect of the patient pathway you want to focus on (e.g. tracking the admission process)
- Develop a template to capture key timings e.g. the time patient arrived, time first seen by clinician, time referred for test. See process templates
- Ensure the shadower fully understands and is comfortable with their role
- Ensure the patient fully understands and is comfortable with their role; get their informed consent to participate
- Write an information sheet about the aims, what is involved and the expected outcomes of the study that can be given to the patient
- Make it clear that the presence of the shadower will not influence the care the patient receives
- Observe how the patient is treated by members of staff
- Observe how easy / difficult it is for the patient to find their way around the hospital
- What goes smoothly for the patient?
- Are any tasks duplicated?
- Observe the environment
- Provide support for the patient and shadower; acknowledge their time and effort
- Feed back to the patient and the shadower how their work has helped with service improvement.
Ways of recruiting patients, carers and the public
You can use posters or information stands in public areas to publicise a project or ask for volunteers. You then need to identify people who will be attending at a particular stage of treatment. There are several ways that you can do this:
- Make use of contacts in the community
- Think about where your target group might be found e.g. working men’s clubs, libraries, Women’s Institute, playgroups, community centres
- Use the voluntary sector if appropriate
- Use local networks in your area
- Ask your PALS manager
- Use existing patient / carer representatives
- Hold an event to raise awareness e.g. a stall at your local market, fete or community fair.
Using patient questionnaires to prioritise areas for action
Poole Hospital NHS Trust compiled an action plan based on their outpatient survey responses. They identified three main areas for action:
- Communication with patients prior to their appointment
- Information given to patients
- The quality of the appointment itself.
The action plan was distributed to all staff working within the outpatients department and also to staff in areas such as X-ray, pathology and pharmacy who regularly interacted with patients attending outpatient appointments. The action plan formed part of the trust’s quarterly Governance Development Plan report submitted to their strategic health authority. A follow up study took place some months later. This consisted of interviews with individual patients following their consultations and concentrated on clinics where there was evidence of long waits and possible organisational difficulties.
The findings were, in the main, very positive and the attitude and professionalism of staff was praised. Areas of concern mirrored those previously identified in the survey.
Using patient shadowing to identify where improvements are needed
As part of the redesign of a colposcopy service in the Home Counties, patient shadowing was used to identify possible areas of improvement from the patient’s perspective. The aim was to collect information about a number of factors including:
- Actual time spent waiting or being seen
- The standard of verbal, printed and signposted information
- Staff responses to questions and specific needs
- The ambience of each area visited.
During a three week period, three surgeons each had clinics shadowed. The clinic nurse approached patients, explained about shadowing and gave them the information sheet. The patients who agreed to participate were told that they could ask the shadower to stop at any time.
The shadower waited with the patient, following them wherever they went and asked appropriate questions. During the consultation or procedure, the shadower remained either in the waiting area, or discreetly in the background, observing. After each activity, the shadower asked for the patient’s reactions to what had happened. The patient was able to see what the shadower was writing if they wanted. After the appointment, the shadower asked general questions: what could have been done better? What was particularly good? The patient also had the opportunity to add anything they chose. After the patient left, the shadower added his or her own comments in the box provided. Clinic staff comments were also recorded.
- The length of waiting time: in outpatients and for appointments
- That a pessaries label was easily visible, causing patients to think it was part of their treatment
- The need for a recovery area as patients did not always feel ready to drive home immediately after treatment
- That they wanted some way of obtaining refreshments without walking outside the building.
- That conversations in side rooms could be heard in the treatment room
- That the consultant had to wait while the patient was with the nurse before and after treatment.
As a result of the exercise, these changes were made:
- Music is now played in the waiting area and in the colposcopy room
- The pessaries label has been removed
- The appointment system has been redesigned to include pooled referrals and partial booking
- The colposcopy unit has been soundproofed
- A second nurse in the clinic means that the doctor is not kept waiting, so more patients are now seen.
Depending on the stage you have reached in the improvement project will determine what your next steps are. However, whatever stage you are at, you must always feed back to the patients involved how their information is being used. You should also combine your patient perspectives with any quantitative data that you have collected to help shape any changes to the service .
Below are a number of tools that may be useful once you have collected your patient perspective:
: ‘Involving Patients and Carers’
Picker Institute Europe
These fact sheets are designed to help healthcare organisations share approaches to improving patient care. Each issue focuses on a specific theme and features examples of good practice which have made a real difference to patients.
More information on .
‘A Guide to Using Discovery Interviews to Improve Patient Care’
The involvement of patients, carers and the public in decision making is at the heart of the modernisation of the NHS, and is now a central theme of national and local policy.
The Kennedy Report on the Bristol Royal Infirmary Inquiry is acknowledged to have had a great impact on the delivery of healthcare in the UK. Published in July 2001, the report recommended that ‘the perspectives of patients and of the public must be heard and taken into account'.
Building on patient experience helps to shape a health service that is truly responsive to patients’ needs and is integral to improving patient satisfaction.
Acknowledgements / sources
Improvement Leaders' Guide 'Involving Patients and Carers' - NHS Institute for Innovation and Improvement
Robert James, Patient Consultant