NDARC Technical Report No. 194 (2004)
Patient involvement in service delivery forms a key element of the NSW Methadone Clinic Accreditation Standards (MCAS) (2000). Processes in NSW to engage with opioid dependent patients about pharmacotherapy services are limited however, and differ between clinics.
An opportunity thus existed in NSW to develop a rigorous, effective and affordable quality improvement tool that would engage with patients, and collect evidence to meet the accreditation requirements articulated in the MCAS.
A project to address this issue was completed in 2004 at Rankin Court, the pharmacotherapy clinic for opioid dependent patients at St Vincent’s Hospital in Sydney. A Public Health Officer from the NSW Public Health Officer Training Program of the NSW Department of Health undertook this project. Project development and implementation was supported by a reference group which comprised membership from the NSW Department of Health, NSW Users and AIDS Association, NSW Methadone Advice and Complaints Service, St Vincent’s Hospital Quality Improvement Unit, and Rankin Court staff.
The project undertook a literature review of consumer satisfaction in health care services (1985 – 2003). At the time of writing, only one instrument had been developed to measure opioid dependent patients’ satisfaction with services from methadone clinics: the Verona Service Satisfaction Scale–MT (VSSS-MT)(de los Cobos 2002). This was judged inappropriate for implementation in NSW due to length, textual complexity, and commensurate resource requirements for its implementation.
An eleven-item self-administered questionnaire and survey protocol was developed by the project. Conceptual dimensions underpinning the questionnaire were drawn from the VSSS-MT and other previously validated patient satisfaction instruments, and corroborated against and extended by qualitative research with opioid dependent patients attending local pharmacotherapy clinics. Conceptual domains in the questionnaire comprised professionals’ skills and behaviours, information, efficacy, access, patient input to health care and overall satisfaction with service. Likert scale responses were used for the majority of the eleven items, drawing on the same response options as the earlier validated instruments. Open ended questions were put regarding desired changes at the clinic, and seeking general comment. Sex, age category, type of pharmacotherapy medication and length of time as patient at the clinic were also asked; no individually identifying information was collected by the questionnaire. Face validity of the questionnaire was addressed by consultation with relevant stakeholders, and by pre-testing with the target population. Low literacy within the target population was addressed in the questionnaire through the use of simplified language, and the addition of visual cues alongside text.
The survey was implemented over four consecutive days in early 2004. The study population was defined as those opioid dependent patients being prescribed and receiving pharmacotherapy through Rankin Court, and who had presented to Rankin Court for dosing at least once in the three days prior to survey commencement (213 patients).
Members of the study population were provided with the questionnaire in the clinic’s waiting room by the project officer, offered the assistance of a consumer representative in completing it, and asked to place it in a sealed box when they advanced to be dosed; clinic staff were separated from data collection, and could not identify respondent by questionnaire – a crucial element in the protocol for data validity with this population.
175 questionnaires were returned by the end of the data collection period, representing an 82% response rate. The average length of time taken to complete the questionnaire was approximately 6 minutes. 108 (61.7%) respondents were male, as were 33 (86.8%) subjects who declined the survey. Age distributions of respondents and those who declined the survey were comparable. 1 (0.6%) respondent and 3(7.9%) subjects who declined the survey were identified as Aboriginal or Torres Strait Islander.
113 (64.6%) of respondents were receiving methadone, 18 (10.3%) buprenorphine, and 44 (25.1%) did not state. 39 (22.3%) of respondents had been a clinic patient for less than one year, while 66 (37.7%) had been a patient for one to five years, 43 (24.6%) had been a patient for longer than five years, and 27 (15.4%) did not state. Concern for anonymity was considered the primary factor for the low compliance with these questions.
Twelve (7%) respondents accepted assistance to answer the questionnaire. Their demographic comparability with that of the overall study population, and high cost per questionnaire, suggest this assistance only be offered in future surveys where there is demonstrated need.
Results generally indicated a high level of patient satisfaction with services. In terms of overall satisfaction, the mean rating of the clinic on a scale from one (terrible) to ten (excellent), was seven. Further, 76% of respondents would either definitely, or with reservations, recommend Rankin Court to a friend who needed treatment. Rankin Court also rated well with respondents in the domains of efficacy, information, and professionals’ skills and behaviours (where 68%, 58%, and 83% of respondents respectively considered the clinic’s service as mostly satisfactory or excellent). Respondents were less positive when questioned in regard to the clinic’s access: only 44% of respondents considered the clinic’s physical environment for patients to be mostly satisfactory or excellent, and only 40% of respondents reported the same level of feeling in regard to Rankin Court’s response to complaints. Results varied in the domain of patient input to health care: while 63% of patients considered their inclusion in decisions about their treatment was mostly satisfactory or excellent, only 27% reported the same feeling when asked about their inclusion in decisions on how the clinic is run. Thematic analysis of free text responses determined that the most commonly desired changes at the clinic pertained to dosing hours, patients’ access to takeaway pharmacotherapy, and clinic staff’s attitudes and practices.
By responding to patients’ requests, Rankin Court will build patients’ trust in the clinic’s accountability to consumers, and in the patient satisfaction survey as a meaningful feedback loop to clinic management. The survey, and Rankin Court’s response, will significantly contribute to the clinic’s accreditation under the MCAS. Annual re-implementation of the survey will support longitudinal assessment of the clinic’s performance.
For pharmacotherapy clinics in NSW, the questionnaire and protocol described in this report represent a rigorous, easy to implement, low cost, and effective quality improvement process to engage with patients and meet the accreditation requirements articulated in the MCAS.
1. That the NSW Department of Health encourage members of the NSW Health Drug and Alcohol Council to:
a. evaluate consumer satisfaction regularly within pharmacotherapy settings, and
b. consider the contribution that could be made to such evaluation by the satisfaction questionnaire and survey protocol described in this report
2. That the NSW Department of Health consider the promotion of the patient satisfaction questionnaire and survey protocol described in this report to private public pharmacotherapy clinics in NSW, within the context of quality improvement.
3. That the NSW Department of Health, in consultation with other stakeholders, promote the development and implementation of consumer satisfaction evaluative processes within other alcohol and drug treatment and health promotion services, eg. needle and syringe programs, detoxification services, residential rehabilitation services, etc.
4. That relevant Health Department staff, drug user organisations, and other stakeholders in other Australian states, consider the potential of the patient satisfaction questionnaire and protocol described in this report for quality improvement in pharmacotherapy clinics for opioid dependent persons in their jurisdictions.
5. That Rankin Court Treatment Centre reviews its services in light of the results from the patient satisfaction survey described in this report, and where possible, amends services to reflect patients’ opinions; further, that Rankin Court Treatment Centre communicates promptly and clearly to patients on the process and outcome of this review.
6. That Rankin Court Treatment Centre embeds the patient satisfaction survey described in this report as an annual feature of its quality improvement framework.
7. That Rankin Court Treatment Centre undertakes further testing and modification of the patient satisfaction questionnaire to improve respondent compliance with its demographic data collection, prior to re-implementation.
Citation: Kehoe, P. & Wodak. A. (2004) Patient satisfaction in a NSW public opioid pharmacotherapy clinic: measurement and responses, Sydney: National Drug and Alcohol Research Cetnre.