key: cord-1018166-uov336bb
authors: Koning, Clare; Lock, Adinet; Bushe, Judy; Guo, Charles
title: Patient Satisfaction With Heart Health Clinics in Fraser Health, Canada
date: 2021-01-20
journal: J Patient Exp
DOI: 10.1177/2374373520981475
sha: 63349d6625bae64a37c495e1435853e9c8a1ebb2
doc_id: 1018166
cord_uid: uov336bb

The Fraser Health heart function clinics explored patient satisfaction using a survey with the goal of understanding and improving care and service delivery. Data were collected from 124 respondents at 3 ambulatory care sites in the region. Patient satisfaction scores were high, with an average score of 8.85 out of 10 and 95% of respondents rating the service higher than 6 out of 10. The results highlighted the importance of multidisciplinary teams, good communication, adequate information, and emphasis on how a patient is treated. The patient’s understanding of the information provided and of their heart health treatment plan were identified as two areas that require greater awareness.

Heart function clinics form a pivotal part of postdischarge care following a cardiac-related hospital admission. Those referred to the heart function clinics in Fraser Health are usually older than 70 years and, depending on the severity of the disease, may require bimonthly follow-up visits until they are stable on a treatment plan, with routine visits every 6 months to a year thereafter. The teams working in these ambulatory care settings are specially trained in the management of cardiac chronic disease with the goal of preventing readmissions and improving quality of life for those affected (1) . In Fraser Health, a heart function visit may include physician and nurse clinician consultation, dietician coaching, group healthy heart education, and pharmacist medication review.

Cardiac illness and its disease trajectory affect not only the patient but their family and relationships too (2) . Patients who attend the heart function clinics have information needs, can be experiencing psychological distress, and often need significant medication management (3) . Understanding the patient experience gives the provider the opportunity to improve patient satisfaction. While patient satisfaction is a key indicator of the quality of care provision and system reliability and safety (4) , it largely depends on the expectations and perceptions of the service user (5) . Recently, there has been an increased focus on quality of health services (5) . Quality is the degree to which health services increase the likelihood of the desired health outcomes in the individual (6) . This has driven a movement to explore how cardiac care influences patient experience. Evidence indicates that cardiac patients are more satisfied when nurses and medical practitioners are kind (4) and knowledgeable (4, 7, 8) , when they receive high-quality individualized interactions (4, 9) , and when they have positive treatment outcomes. Patient satisfaction is a determinant of adherence to secondary prevention strategies (1) and a key indicator of healthcare quality (3) . The goal of the quality improvement initiative reported here was to conduct a patient satisfaction survey in 3 heart function clinics of Fraser Health Authority, Canada, to explore patient experience and improve service, quality, and care delivery.

Data for this quality improvement initiative about patient satisfaction with heart function care were obtained from a survey (Online Appendix 1) conducted at 3 heart function clinics (Royal Columbian, Abbotsford, and Langley) in the Fraser Health Authority, located in British Columbia, Canada. A 14-question paper survey measured satisfaction from a convenience sample of 124 patients who attended clinics over a 3-month period between February 1, 2020, and May 1, 2020. The survey was distributed and collected by the clinic staff and provided at the time of check-in for the clinic appointment. The survey collected both quantitative and qualitative data and was designed by a regional working group and approved by the Fraser Health Authority Information Privacy Department on January 7, 2020, ensuring ethical conduct of this quality improvement initiative. Patients provided verbal informed consent to participate, but a family member could fill out the survey on the patient's behalf. A written copy of the consent was provided at the beginning of the survey (Appendix 1). No personal identifying information was collected.

A descriptive analysis was performed using data frequency and code tables to sort and organize the data in a meaningful way. Of the 124 respondents who returned the surveys, 27 did not complete every question and 16 family members assisted patients in completing the survey. Overall, the outpatient service was rated highly (Figure 1 ). Respondents were asked to rate the outpatient service on a scale of 1 to 10 (with 1 being the worst and 10 being the best). Ninety percent of participants responded (n ¼ 112) to this question, with 46% (n ¼ 52) reporting a top score of 10, 91% (n ¼ 102) reporting scores between 8 and 10, and 95% (n ¼ 106) reporting scores between 6 and 10. The average score when rating the service was 8.85. Only 5% (n ¼ 6) reported a score less than 6 out of 10.

Most respondents (96%) rated friendliness and responsiveness of staff as very good or excellent; 90% said they were always treated with dignity and respect; 88% said their privacy was always respected and maintained; and 77% said their healthcare providers always listened to what they had to say ( Figure 2 ). Although 91% of respondents were satisfied with the information provided about their condition and treatments, only 66% always understood the answers to the questions they asked and only 27% of respondents reported having an excellent understanding of their heart function treatment plan. However, the majority (67%) reported a good to very good understanding. Most respondents (83%) found it always helpful to meet with the nurse practitioner (NP), while 70% found it always helpful to meet with the pharmacist, dietician, and registered nurse (RN). Telephone visits were always helpful for 83% of respondents, and approximately 93% felt always or usually confident in making independent decisions about their heart health at home.

In order to target quality improvement efforts at the services that were rated with the highest importance, further analysis was conducted on a subset of the highest satisfied respondents. By isolating the responses of those most satisfied, the intent was to show which aspects of services provided were most likely to contribute to high satisfaction scores. Analysis of the 52 respondents who reported complete satisfaction with the care (rated 10 out of 10) showed that the highest frequency of positive responses were grouped into the following categories: how patients were treated (questions 1, 5, and 6), the information provided Rating the satisfaction with the cardiac clinic service (n=112) (1= worst service, 10 = best service) (question 8), the interaction with the multidisciplinary team (questions 2, 9, 10, and 11), communication (questions 3 and 7), and understanding of heart health (questions 4 and 12).

The lowest frequency of positive responses was about the level of understanding of their treatment plan and confidence in making independent decisions about their heart health at home (Figure 3 ). Seventy participants responded to an open-ended question asking what patients would like to improve about the heart function clinic care. Overall, narratives were very positive, with comments like: "I feel that the clinic runs well and have been reassuring when I was anxious and answered my questions"; and "The nurses, pharmacist, receptionist were all attentive to my needs and all are pros." The most common narrative theme was the importance of interacting with the multidisciplinary team, which was mentioned by 59% of the respondents, with interaction with the pharmacist and RNs being mentioned the most. While most narratives were very complementary of the staff and service, some negative aspects were noted. Six percent (n ¼ 4) of those who responded with narratives were unsatisfied with the amount of available parking and the lengthy distance to drive for appointments. Comments included: "More parking spaces needed" (participant rated the service 9 out of 10); "I wish there was a closer program" (participant rated the service 2 out of 10). Other negative comments were about wait times and needing more information about medication side effects.

Knowledge of patient satisfaction could help to improve the quality of care and services delivery in healthcare clinic settings (9) . A patient's positive assessment of a healthcare service, based on expectations and importance, can be regarded as satisfaction (10) . The outpatient service was highly rated by participants, and therefore, it could be inferred that patient satisfaction with the cardiac clinics was high. There were similar themes evident in the qualitative and quantitative data with parallels in the frequency of responses and the frequency of topics in the narratives. These factors and themes include how respondents were treated, communication, information, and the interactions with the multidisciplinary team. Assessing how respondents were treated included questions about respect, dignity, friendliness, confidentiality, and privacy and reflects the high quality of interpersonal relations at these heart function clinics. Patient expectations are largely influenced by previous experiences and perceived vulnerability (11) . The value that these participants placed on how they were treated could be an indication of their favorable treatment experience in the past. The heart function clinics have multidisciplinary teams including NPs, physicians, RNs, unit clerks, registered dieticians, pharmacists, case managers, social workers, and so on. Interaction with all disciplines in one area has benefit for patient care, education, and team collaboration (11, 12) and also limits the frequency of visits that the patient needs to make. This could explain satisfaction reported with wait time and helpfulness reported in meeting with respective health practitioners. Only one participant was dissatisfied with the wait time, and some experienced barriers to access such as lack of parking and long driving distances to the clinics. These issues have since been minimized by moving to a virtual-first approach due to COVID-19. This new model of care prioritizes virtual visits over in-person visits and eliminates the wait, travel, and parking issues for the majority of heart function clinic patients.

Communication and information are 2 aspects of care that showed high satisfaction scores. Survey questions relating to communication included whether participants received answers they understood when they asked questions and whether providers listened to participants. The survey question about information asked whether participants received enough information about their condition and treatment from their providers and whether participants learned enough at the clinic to make independent decisions about their health. The unique provider-patient relationship and power-knowledge balance exists in this setting (11) , and these results could indicate a healthy and balanced professional relationship. Patients' positive rating of the communication and information questions above could indicate that care is provided in a person-centric and culturally sensitive way (12) , encouraging patients to achieve the expected positive health outcomes while taking an active role in their own health (13) . Of interest is that those who were most satisfied (10/10) showed a lower frequency (27%) in having an excellent understanding of their treatment plan. This could indicate an overreliance on the healthcare team for decision-making and expert advice. The majority of heart function patients suffer from chronic disease and half die within 5 years of diagnosis (14) . The lack of understanding is concerning as many modifiable factors are still within the patient's control and could help to empower them in their disease self-management. The concern also relates to expectations and health outcomes if there is a lack of understanding, which could include negative effects on morbidity, hospital readmission rates, and burden of the disease. Many factors contribute to individual understanding. Of note is that 91% of the total respondents were satisfied with the amount of information provided; this includes verbal and written communication methods provided by clinic staff. While this is positive feedback, the clinic staff themselves report that much of the available resource materials are lengthy, and even with clear verbal explanation of heart health concepts, patients rarely retain the information. Research shows that up to 80% of healthcare information is forgotten immediately after it is provided, and only 50% of that which is retained is accurate (15) . In addition, the percentage of information lost increases with age and time since the information was received (15) . In communication with Fraser Health frontline healthcare providers (June 15, 2020), there is an expressed need for a more simplified and repetitive approach to improve patient understanding.

Quality improvement strategies designed around goal-orientated communication, professional relationship building, and teaching self-management skills could be helpful to improve communication and patient satisfaction. In addition, incorporating adult learning theories into instruction, like reflecting on past experiences, highlighting relevant concerns, problem solving, and applying learning to practice, could help with understanding and retention of information. Using patient narratives as tools for teaching and learning is beneficial when bridging the gap between theoretical content and practical application. Furthermore, incorporating humor and stories into education has value in connecting health content with patient interests and could enhance self-management of chronic disease (16) . While respondents deemed the amount of information sufficient, the method of information delivery could be improved to enhance retention. Tools that may improve patient understanding of information are using multimedia, including visual aids, avoiding medical jargon, and utilizing teach-back techniques (17) .

Several limitations were identified in this quality improvement initiative. Survey research has limitations, such as the misinterpretation or misunderstanding of survey questions (18) . The survey was not validated or tested, and the results may not be generalizable to other populations. There was a negative impact on data collection due to COVID-19 in-person visit restrictions, and descriptive Highest ranked categories for those who were 100% satisfied with the heart function clinic service survey research is limited to describing the data collected and cannot draw causal relationships. Future research could explore healthcare provider communication strategies and factors that can enable patients to better understand and remember their treatment plan. Future patient satisfaction surveys should include validated and tested surveys. Eight percent of the total respondents failed to complete the second page of the survey. To avoid this, the recommendation is to keep all survey questions on one page or check each survey for completion. Lastly, future studies could explore the correlation between quality care, patient satisfaction, and health outcomes. Data from patients with heart failure indicate that high quality care results in both patient satisfaction and good health outcomes (1, 3) . When analyzing heart failure-specific 30-day readmission rates at the 3 sites that participated in this quality improvement initiative, and comparing those to national standards, the results are favorable. The average heart failure-specific 30-day readmission rate from January to April 2020 was 6.0% for the 3 sites. This is 0.9% lower than the Canadian average of 6.9% (19) . This could imply that the higher levels of satisfaction result in lower readmission rates and improved health outcomes and would be a suggestion for future research.

The goal of this quality improvement initiative was to explore patient satisfaction with the intent of improving service, quality, and care delivery. The patient satisfaction rates in these Fraser Health regional heart function clinic locations are high, and many positive aspects have been highlighted that should be applauded. Having gained a greater understanding of areas patients are most and least satisfied with may help healthcare professionals at heart function clinics focus their efforts and to take a systematic approach to improving performance and patient health outcomes.

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The authors greatly appreciate and would like to thank all the heart function clinic staff at the 3 sites in the region who collected the survey data from their patients, as well as the patients who responded to the survey.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C.K., C.G., and J.B. are paid employees of Fraser Health.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Clare Koning, RN, MN, PhD(c) https://orcid.org/0000-0003-4988-5797

Supplemental material for this article is available online.

Clare Koning is the Clinical Nurse Specialist for Cardiac Service in Fraser Health.Adinet Lock is a freelance public health specialist, researcher, and medical writer.Judy Bushe is the lead nurse clinician at the heart function clinic in Abbotsford General Hospital.Charles Guo is the lead nurse clinician at the heart function clinic in Royal Columbian Hospital.