The patient satisfaction questionnaire in GP training

How the patient satisfaction questionnaire (PSQ) is used in GP training and how trainees should reflect on the feedback they receive.

According to the RCGP, the patient satisfaction questionnaire (PSQ) provides patient feedback on the trainee's empathy and relationship-building skills during consultations.
In advertising speak, it's about customer satisfaction with doctors' consulting skills.

It is important that patients are satisfied with GP consultations – increased satisfaction has been shown to lead to improvements in symptom relief, in clinical outcomes and possibly in medication adherence.

Not everybody agrees that customer satisfaction is a good thing. Some argue that as GPs, part of the job is to reset expectations and surely GPs can't give everybody everything they want all of the time. However, the PSQ is mandatory in GP training and revalidation.

What is involved in the PSQ?

The PSQ process seems more labour intensive than multisource feedback (MSF) because the sample size is 40, whereas it is five to 10 with MSF, and unlike MSF paper questionnaires are preferred to electronic sampling. This means that someone in the practice team has to input the data into the RCGP website.

The RCGP usually produces a summary of the results within 24 hours and sends this to the educational supervisor (ES). Results are anonymous. Results are given as scores: lowest, highest, mean and median, based on marks awarded by patients from 1 (poor) to 7 (outstanding).

The ES releases the results to the trainee and CS, who debriefs the trainee. Trainees are expected to reflect on the collated data, the discussion, and the resulting action plan in their ePortfolio Learning Log.

An ST1 has to undertake a PSQ if in primary care; a ST2 only needs to do a PSQ if in primary care and if they have not already completed a PSQ in ST1; and a ST3 has to do one PSQ.

The questionnaires and letters of explanation should be handed to consecutive patients by the receptionist, whether or not they are likely to respond. This process should continue until a minimum of 40 forms have been returned. Patients should return the questionnaires to the receptionist.

An example PSQ

PSQ Summary

Submission Date: 14 February
Name: Dr Tina
Number of PSQs filled: 40
scale: ranging from 1 = poor to 7 = outstanding

Questions Low High Mean Median
1. Making you feel at ease… (being friendly and warm towards you, treating you with respect; not cold or abrupt) 5 7 6 7
2. Letting you tell "your" story… (giving you time to fully describe your illness in your own words; not interrupting or diverting you) 5 7 6 6
3. Really listening… (paying close attention to what you were saying; not looking at the notes or computer as you were talking) 5 7 6 7
4. Being interested in you as a whole person… (asking/knowing relevant details about your life, your situation; not treating you as "just a number") 4 7 6 7
5. Fully understanding your concerns… (communicating that he/she had accurately understood your concerns; not overlooking or dismissing anything) 5 7 6 6
6. Showing care and compassion… (seeming genuinely concerned, connecting with you on a human level; not being indifferent or "detached") 5 7 6 6
7. Being positive… (having a positive approach and a positive attitude; being honest but not negative about your problems) 4 7 6 6
8. Explaining things clearly… (fully answering your questions, explaining clearly, giving you adequate information; not being vague) 5 7 6 7
9. Helping you to take control… (exploring with you what you can do to improve your health yourself; encouraging rather than "lecturing" you) 4 7 6 6
10. Making a plan of action with you… (discussing the options, involving you in decisions as much as you want to be involved; not ignoring your views) 5 7 6 7
11. Overall, how would you rate your consultation with this doctor today? 5 7 6 7

Comments
Your scores typically range between 4-7: in other words one or more patients gave you  a score of 4 (=good) and  one or more patients gave you a score of 7 (=outstanding) and the rest somewhere in between. The narrow range (4-7) tells me that we can be trust this sample and draw conclusions.

If there was a wide range (1-7), I would not be able to trust the sample and it would be difficult to draw conclusions. In questions 2/5/6/7/9, the mean score (6) was the same as the median score (6), so a score of 6 is typical for you.

In questions 1/3/4/8/10/11 your mean score (6) was less than your median score (7), so more than 50% of the scores were above the mean of 6 so actually your typical score was probably higher than 6 (probably 7).

What was good about your results: Most of your patients in this sample of 40 rated your empathy and relationship-building skills as 6 (excellent) or 7 (outstanding). This is fantastic feedback – well done!
 
Possible areas for improvement: Your lowest scores of 4 (= good) were in the following 3 areas:

  • Being interested in you as a whole person
  • Being positive
  • Helping you to take control

Based on our joint consultations and your out-of-hours feedback, I feel your holistic care (1) is good. Points 2 and 3 could be areas to examine – how could you appear more positive and empowering to patients? What phrases might be useful? Please remember that overall, this was an amazing PSQ, so these suggestions are only small and tentative. If you continue to consult in this manner, without making any changes, and continue to get this type of customer feedback, your future appraisers would be ecstatic.

Reflection on the PSQ

When Dr Tina writes her 'professional conversation' learning log, she needs to reflect on
the positive outcomes

  • possible learning needs identified
  • based on the feedback, what specific behaviour(s), if any, would she like to change?
  • what learning does she need to undertake to help her make these changes?

She should also discuss how undertaking the PSQ helped her development as a GP, for example, whether it increased her confidence and moral. She may wish to outline any new learning needs she identified and propose learning activities to address them.

Do patients with higher expectations give lower PSQs?

A BMJ article looked at how patients’ characteristics influence responses to questions about satisfaction with health care services.1 The study questioned whether low or high PSQ scores reflected different expectations rather than differences in the care provided.

The study said: ‘If patients’ experience is related to expectation rather than to performance of the practice, then failing to adjust practices’ scores for the characteristics of the population of patients could lead to systematic misrepresentation of the performance of practices that cater for particular patient groups, such as those from ethnic minorities...... However, if the lower scores reported by certain types of patient reflect a lower quality of care, then adjusting practices scores would mean that inequitable care provision would not be identified.’
 
Interpreting scores

The final word goes to Dr Ramesh Mehay, programme director, Bradford VTS for his work on interpreting PSQ scores - basically use the median value.

If mean = median The mean/median scores reflect what the trainee typically got
If mean < median The mean UNDER estimates the typical score.  The typical score the trainee got was more than what the mean states.  Use the median value.
If mean > median The mean OVER estimates  the typical score.  The typical score the trainee got was less than what the mean states.  Use the median value.
  • Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in January 2016.

Reference

1. Salisbury C, Wallace M, Montgomery AA. Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling. BMJ 2010; 341 doi:

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