Test 6

CHAPTER 6 Measuring Consumer Satisfaction

Shulamit L. Bernard and Lucy A. Savitz

“The key to customer feedback is to ask about the few aspects of the customer experience that matter the most … and do something about them!”

—Davis Balestracci ( 2009 )

Measures of consumer satisfaction can serve an important role in monitoring quality and improving health care. Oftentimes overshadowed by measures of clinical process and outcomes in monitoring health care quality, consumer satisfaction has emerged as an important indicator of quality (see Chapter 5 ). At one time relegated to service improvement efforts by hospitals, measures of patient—or consumer—satisfaction are recognized as the provider’s best source of information about “communication, education, and pain-management process, and they (patients) are the only source of information about whether they were treated with dignity and respect” (Cleary, 2003 , p. 33). Consumers’ experiences can stimulate important insights into how a provider is operating and suggest changes that may “close the chasm between the care provided and that care that should be provided” (Cleary, 2003 , p. 33). Furthermore, the marketplace in which the providers operate is demanding that data on patient satisfaction be used to empower consumers and foster provider accountability and consumer choice. Measuring consumer satisfaction provides a comprehensive, systematic, and patient-centered approach for analysis, implementation, monitoring, and improving both the perceived and the clinical quality aspects of care (Ford et al., 1997 ).

This chapter provides an overview of key issues and methods related to measuring consumer satisfaction. The rationale for measurement is discussed and followed by a series of issues: measurement, data capture, timing, and functional responsibility. An example applying patient satisfaction measures as part of the Balanced Scorecard (a measurement system that adds customer and other dimensions to the customary financial measures [Kaplan and Norton, 1996 ]) is presented. We conclude with a brief overview of the special issue of case-mix adjustment of reported consumer satisfaction measures.

DEFINING CONSUMER SATISFACTION

Obtaining the views of customers has been a key feature of many modern business practices for many years, and the health care sector has adopted this same view, considering the patient as a consumer, which has led to the application of methods for assessing patient views (Wensing and Elwyn, 2002 ). The idea of patients as consumers stems from a market perspective on health care in which the providers are assumed to be responsive to competition and in which competition can drive increased quality and lower cost. In the context of satisfaction measures, patients are considered as parties to an exchange of goods and/or services. Health consumers’ views can be divided into three types: measures of preferences, evaluations by users, and reports of health care. Preferences are ideas about what should occur in the health care encounter. Evaluations are patients’ reactions to their experiences of health care, or whether the process or outcome of their care was good or bad (Pascoe, 1983 ). Reports are objective observations of an organization or a process of care. They are independent of preferences or evaluations; for example, a report may assess the waiting time for an appointment or response from a nurse (Wensing and Elwyn, 2002 , 2003 ).

The model used to explain postpurchase satisfaction suggests that consumer satisfaction can be defined simply as “the evaluation rendered that the experience was at least as good as it was supposed to be” (Hunt, 1977 ). Postpurchase satisfaction is classically derived by the relationship between the consumer’s expectations and the product’s (or service’s) perceived performance (LaBarbara and Mazursky, 1983 ). If the rendered service or product meets or exceeds expectations, then the consumer is satisfied; if the rendered service or product does not meet expectations, then the consumer is dissatisfied. The Buyer-Decision Process (Kotler and Armstrong, 1997 ) can be summarized in five steps:

· 1. Recognition of the problem

· 2. Information search

· 3. Evaluation of the alternative(s)

· 4. Choice of the best option

· 5. Postpurchase behavior

Here postpurchase behavior is directly preceded by four steps that shape expectations against the level of satisfaction that will ultimately be reported. Furthermore, the extent to which consumers spend time moving through these steps is largely associated with the nature of the health care problem being addressed. In the model, the key attributes of the health care concern are complexity, amount of patient discomfort, degree of patient involvement, and urgency. For instance, a mother recognizing that a healthy child is in immediate need of a routine sports physical to comply with a school requirement might skip the information search step and turn to the telephone directory to identify the closest walk-in clinic for a quick appointment. Once the most convenient and timely provider is identified, the purchase decision is made with relatively little investment in the choice. Walking out of the physician’s office within 30 minutes and having paid a minimal fee to secure a completed form so that her son could sign up for a team sport may leave both mother and son quite satisfied with the medical encounter. This example can contrast sharply with patients seeking higher-order services or services where the doctor–patient relationship is extended over a protracted time and where the patient perceives a need to make critical choices (e.g., organ transplantation, cancer treatment, prenatal care and delivery, nursing home care).

Application of this marketing model to health care is further complicated by the fact that choices and preferences may be severely limited as a result of health insurance limitations, constraining patient choice and/or physician referral options. The complexity of patients’ perceptions and attitudes, together with their sometimes limited cognitive ability to process the nature of their own health care situations, serves to further complicate the decision process beyond attributes of the immediate health concern.

Expectations and preferences are also shaped by a variety of inputs, such as personal experiences, experiences of family and friends, physician recommendations, and directed advertising campaigns.

WHO IS THE CONSUMER?

The consumer, in general, can be viewed as the party using the provided service and/or product of the exchange. From a health care perspective, the consumer is typically assumed to be the patient in a clinical setting or the enrollee in a health plan. The consumer is the recipient of a direct exchange of health care services, and it is this perspective that serves as the basis for the majority of discussion in this chapter. Consumers in health care can include both internal customers (e.g., providers and suppliers) and external customers (e.g., patients and their families as well as communities and government agencies). Thus, measures of consumer satisfaction may broadly target family members, practitioners, staff, and contract service administrators. Examples of other consumers beyond the basic patient–provider exchange are illustrated as follows:

Physicians as consumers:

· • Community doctors referring patients to a tertiary care center are consumers of that center.

· • Physicians sending specimens to labs for testing and/or ordering scans from radiology centers are consumers of that ancillary service.

Facilities as consumers:

· • Hospitals purchasing information systems to monitor the quality process are consumers of these vendors.

Insurers and managed care organizations (MCOs) as consumers:

· • Insurers outsourcing claims processing functions are consumers of the third-party service.

· • MCOs contracting with physicians, pharmacies, clinics, hospitals, and home health agencies to provide a continuum of care for their health insurance benefits are consumers for the providers and facilities.

Government agencies as consumers:

· • Centers for Medicare and Medicaid Services (CMS), by contracting with insurers to provide Medicare and Medicaid risk coverage for eligible beneficiaries, is a consumer for the MCOs.

· • State and/or federal prisons, by contracting with health care facilities and providers for services for the incarcerated population, are consumers of these facilities and providers.

Beyond recognizing the roles of these parties in providing a range of health care and health care–related services, it is also important to note the roles of others, such as health care workers, suppliers, communities, and families. In particular, families often act as a key agent in the market exchange for health care services, such as for minors and frail elderly family members, and have often reported either directly or indirectly as proxies concerning patient satisfaction (Schweikhart et al., 1993 ). However, their perspective, while valuable, must be distinguished from that of the individual experiencing the health care service firsthand. In considering the various consumers of health care, it is important to recognize that patients, providers, and payers all define quality differently. These differences result in different expectations of the health care system and, thus, differing measures of satisfaction in evaluation of quality (McGlynn, 1997 ).

WHY MEASURE CONSUMER SATISFACTION?

We are in an era when health care consumers want to assert more control over dollars, and many are willing to pay out-of-pocket for quality. Technologically savvy patients and families are surfing the Web and demanding information about health care problems and provider performance. In addition, as hospitals are under pressure to increase the quality of care, ensure the safety of their patients, and lower operating costs, greater attention and scrutiny are being given to the accountability function of consumer satisfaction scores. In this competitive health care environment, consumers want and expect better health care services and hospital systems are concerned about maintaining their overall image. There is also attention to ways in which patient satisfaction measurement can be integrated into an overall measure of clinical quality.

Consumer satisfaction provides a useful outcome measure for quality of care offered by a health care organization.

Ford et al. ( 1997 ) review the literature that reports benefits of measuring patient-enrollee satisfaction attributable to the following factors: increased profitability, increased market share, improved patient retention, improved collections, increased patient referrals, improved patient compliance, continuity of care, reduced hospitalization and length of stay, increased willingness to recommend the organization to family and friends, and reduced risk of malpractice. Satisfaction measures, together with clinical outcomes and cost data, are increasingly used by employers as part of their value-based purchasing of health care benefits, by insurers in contracting for network services, and by potential partners in establishing health care alliances and systems (Woodbury et al., 1997 ).

TABLE 6–1 Rank of Factors Influencing Choice of Hospital

· 1. Expertise in specific illness/treatment · 2. History of medical errors · 3. Doctor referral/doctor’s orders · 4. Courtesy of staff · 5. Hospital location · 6. Appearance of hospital/facility · 7. Recommendation of family/friends · 8. Consumer report cards · 9. Insurance coverage · 10. Public information (marketing/Web site) · 11. Amenities (food, parking, etc.)

Source: Blizzard, 2005.

Quality, loyalty, and satisfaction have important implications for future utilization of hospitals, and all three factors are correlated with the degree of success of overall hospital experience. Expertise in specific illnesses and/or treatment and the history of medical errors have emerged as the most important factors influencing the public’s choice of a hospital (Blizzard, 2005 ). Table 6–1 shows how respondents to a 2005 Gallup poll panel survey on health care ranked specific factors when choosing a health care facility or hospital. Almost two-thirds of those who responded to the survey indicated that medical expertise “had a great deal of influence in their choice,” and more than half said the same of medical errors, reflecting growing patient awareness and concern about quality and safety in their choice of hospitals.

Clearly, there is a direct link between patient satisfaction and market share driven by repeat utilization. In addition, positive intermediary influences on compliance and provider change are key with respect to health care behaviors, and loyalty and word-of-mouth advertising are related to reputation. For instance, word-of-mouth advertising has been shown to account for a significant proportion of future encounters whereby satisfied customers tell others about their experiences and refer them accordingly (Davies and Ware, 1988 ; Kotler and Armstrong, 1997 ; Savitz, 1994 ).

External reporting and accreditation requirements made by The Joint Commission and the National Committee on Quality Assurance (NCQA) have heightened the importance of patient satisfaction measures, moving them from internal to external performance monitoring and quality indicators. Patient perspectives on their health care experience have been included in the NCQA annual State of Health Care Quality reports ( 2003 ) along with the clinical Healthcare Effectiveness Data Information Set (HEDIS) measures.

Finally, application of continuous quality improvement (CQI) principles in health care organizations has led to the integration of patient-enrollee satisfaction measures that can be used in identifying improvement opportunities in the key components of care—structure, process, and outcome—as described by Donabedian ( 1982 ).

Taking Action

In addition to regulatory requirements, the fact that the primary purpose of measuring consumer satisfaction is to improve the quality of care provided should always be kept in mind. This principle should be a guide in what data are collected, how they are collected, and, most importantly, how they are analyzed and reported. As Balestracci warns, “Remember data are a basis for action: vague data with vague objectives yield vague results” (2009, p. 269).

Balestracci goes on to remind us that consumer data should be collected with the idea of identifying trouble areas and not simply validating what we already know; furthermore, taking action includes summarization as well as communication of findings back to the customer (2009). It all starts with understanding the goals of data collection on the front end of the process.

MEASURING SATISFACTION

Zifko-Baliga and Krampf ( 1997 ) found that patients used more than 500 criteria to evaluate hospital quality. Personal choice emerged as a significant factor in predicting enrollee satisfaction. In a study done by researchers at Kaiser Permanente, 10,000 adults enrolled in a large group model HMO in northern California in 1995 and 1996 were surveyed. For each of nine satisfaction measures (i.e., time usually spent with physician, explanation of diagnosis and treatment, technical skill of physician, personal manner of physician, use of latest technology, focus on prevention, concern for emotional well-being, patient’s overall satisfaction, and recommendation of physician to others), respondents who had chosen their own physician were 16% to 26% more likely than those who had been assigned a personal physician to report their health care as very good or excellent (Schmittdiel et al., 1997 ). Findings such as these are important to communicate to practitioners an understanding of the exchange process they are involved in and to evaluate appropriate satisfaction measures.

A follow-up study (based on Fletcher et al., 1983 ) conducted by the American College of Physicians (ACP) in 1993 continues to be relevant today. The study included a series of focus groups with patients and physicians to understand the relative importance of measures of satisfaction in office-based medical care as part of the Patient-Centered Care Project. The critical steps suggested in this study are depicted in Figure 6–1 .

FIGURE 6–1 ACP, The Patient-Centered Care Project: Steps in office-based medical care

ACP researchers completed a comparative analysis of physicians’ and patients’ importance rankings for 125 attributes of the medical care encounter. Major discrepancies were found throughout the list, and examples of these are provided in the partial list that follows:

Patient rank	MD rank	Difference	Questions How important is it that …
26	113	87	the doctor explains the results of any evaluation by a consulting specialist to the patients?
80	10	70	the doctor discusses important information about patients’ health in a private place?
12	81	69	the doctor explains the purpose of each medicine prescribed in a way patients understand?
23	79	56	the doctor clearly explains the possible side effects of medicines?
5	58	53	the doctor gives patients solid facts about the likely benefits and risks of treatment?
11	64	53	the doctor tells patients how to take medicines in a way that patients understand?

The ACP study underscores the critical need to measure consumer satisfaction using data from those who utilize the services rather than simply assuming that as providers we understand what patients want and what will ultimately satisfy their expectations. Clearly, practitioner understanding of patient expectations is incomplete. More recent studies confirm that while there is some overlap between clinicians’ and patients’ expectations in crucial elements of quality, there is also disagreement about the relative importance of elements such as access to care, coordination of care, and provision of information. Patients place greater value on these domains than do physicians (Kaya et al., 2003 ).

Sitzia ( 1999 ) analyzed 195 studies that used instruments to assess the satisfaction levels of health service users and found that, with few exceptions, the survey instruments examined demonstrated little evidence of reliability or validity. An additional problem was that although many hospitals were collecting data about patient experience for their own internal use, these data could not be compared across hospitals because the assessment tools were not standardized. To address this issue, in 2002 CMS partnered with the Agency for Healthcare Research and Quality (AHRQ) to develop and test HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which is also known as the CAHPS Hospital Survey. This initiative provided a standard for collecting and publicly reporting information about patient experience of care, which was gaining leverage with employers, payers, clinicians, and the government (Liang et al., 2002 ; Scalise, 2003 ).

After rigorous development and testing, CMS implemented the HCAHPS survey in October 2006. The first public reporting of HCAHPS results occurred in March 2008. Results from hospitals that participate are available at http://www.hospitalcompare.hhs.gov . The HCAHPS survey is 27 questions in length and contains 18 patient perspectives on care and patient rating items that encompass eight key topics:

· 1. Communication with doctors

· 2. Communication with nurses

· 3. Responsiveness of hospital staff

· 4. Pain management

· 5. Communication about medicines

· 6. Discharge information

· 7. Cleanliness of the hospital environment

· 8. Quietness of the hospital environment

The survey also includes four screener questions and five demographic items, which are used for adjusting the mix of patients across hospitals and for analytical purposes. More information about HCAHPS, including the survey instruments, is available at http://www.hcahpsonline.org/home.aspx . The survey, its methodology, and the results it produces are in the public domain.

Data Capture

In general, patient-enrollee satisfaction measures are among the most readily available outcome measures. Accreditation requirements and marketing efforts have already been established to collect these measures without the burden of purchasing new and/or reprogramming existing systems to generate such quality measures, as is the experience with clinical quality measures. It is also important, however, to address issues involved in data capture with respect to how the data will be collected, when the data should be collected, and which functional area will be responsible for data capture and reporting.

With the growing use of the Internet and social media, it is very tempting to assume that these modalities are superior to traditional modes of data capture. Web-based technologies have emerged that greatly simplify the process of data collection and analysis (e.g., http://www.surveymonkey.com/ and http://www3.formassembly.com/ ). While we are fast approaching the time when the Internet will be the most appropriate form of communication with consumers, this is not always the case. Care should be taken to understand what tools the consumers being surveyed will be most receptive to and which will produce the highest response rates and, of course, the most reliable information. Also to be considered is the type of information being collected; for example, open-ended information may still be collected most reliably through face-to-face, point-of-service formats or telephone interviews. Likewise, an important consideration is modality of information.

Alternative Modalities

There are multiple modalities available to health service researchers and health care organizations in collecting patient satisfaction data, which can then be translated into information for CQI purposes. Alternative modalities have important advantages and disadvantages that must be considered together with the data needed in determining how to proceed.

Ford et al. ( 1997 ) provide a comprehensive comparison of advantages and disadvantages associated with various qualitative and quantitative modalities for measuring consumer satisfaction. While a detailed specification of how to capture satisfaction measures using these alternative modalities exceeds the scope of this particular chapter, an itemized listing of these methods with a brief description is presented. There is an extensive literature on each modality that the reader is encouraged to consult as needed.

Qualitative Modalities

· • Management observation—formal observation and documentation of the patient care process

· • Employee feedback programs—formal employee feedback on all aspects of the patient care process

· • Work teams and quality circles—continuous employee input through teams

· • Focus groups—input facilitated through an open-ended forum of homogeneous groups of consumers

· • Mystery shoppers—an observational technique that provides a snapshot of the service experience from a user perspective

Quantitative Modalities

· • Comment cards—voluntary patient-enrollee ratings of service quality

· • Mail surveys—questionnaires mailed to users for completion and return

· • Point-of-service interviews—self-administered or interviewer-administered questionnaires completed usually following service delivery at the delivery site

· • Telephone interviews—personal interviews with users over the telephone by trained interviewers

Critical considerations when comparing these optional measurement modalities involve expense, timeliness of feedback, required staff competencies to develop and administer the measurement instrument, desired depth of understanding, and complexity of the data capture effort. Work teams and quality circles have become a well-established part of CQI efforts, providing useful and timely consumer satisfaction information that is non-episodic. However, this particular method does not offer information that is necessarily generalizable or comprehensive. Comment cards are the least expensive and complex service evaluation technique; however, the results are often biased with respect to the type of consumers who are inclined to respond and the type of information typically provided. A qualitative approach is particularly useful for exploring patients’ views in areas that have not been previously studied (Wensing and Elwyn, 2003 ). In general, any modality offers only a snapshot of the service experience and must be replicated over time in order to provide feedback useful to the CQI process.

A clear understanding of organizational capabilities and commitment together with the intended purpose of satisfaction measures is necessary to select the modality to be used. Selection of the appropriate data capture modality involves learning more about information-gathering techniques and choosing the right technique for the target group and desired depth of information sought. Trade-offs between budgetary constraints and methodological rigor are often central selection criteria.

Timing

Little attention has been paid to the appropriate timing of patient-enrollee survey administration and/or interviewing in the data collection process. Most marketing efforts have done collecting either with a point-of-service survey and/or with a short-term non–service-specific follow-up after discharge/encounter via mail or telephone. As we begin to use such data as part of the CQI process, more consideration should be given to the appropriate timing of such data collection. For instance, it may make sense to query emergency room visits at the point of service; however, follow-up of services with extended recovery periods may be more meaningful if they are conducted at clinically reasonable points in the recovery process (e.g., 6 weeks following care for hip replacements). However, considerations of the recovery process must be balanced with the ability for the patient to provide accurate recall. Survey vendors provide a data collection protocol as part of their service; the HCAHPS methodology also specifies data collection protocols and timing of survey implementation.

Validity and Psychometric Properties

Patient satisfaction survey instruments should be validated to ensure that the questions measure what they are intended to measure. The science has much improved since 1994 when a review of 195 studies of patient satisfaction showed that only 46% reported some validity or reliability data and only 6% reported evidence of measuring the intended domain (Sitzia, 1999 ). Cognitive testing of the survey items with the intended audience should be reviewed as part of an evaluation of a survey instrument under consideration. Survey instruments should also have adequate psychometric features (Streiner and Norman, 1989 ). For example, a high response rate to an item usually indicates that the question is relevant and understandable, while a low item response rate may suggest confusion with the item or response categories (Wensing and Elwyn, 2003 ). Questionnaires that are designed to measure different aspects of quality should demonstrate variation across patients (ability to discriminate) as well as variation between measurements at different points in time (e.g., responsiveness to change and interventions). Once valid and reliable consumer satisfaction measures have been produced, they become a valuable component of the feedback loop in the CQI process. Only through dissemination can this information actually be used for performance improvement.

SATISFACTION AND THE BALANCED SCORECARD

Kaplan and Norton developed the premise for the Balanced Scorecard (BSC) approach through a series of articles that were published in the Harvard Business Review in the early 1990s and later compiled this work with a more in-depth discussion of examples from the field in a book (1996). In addition to strict financial outcomes, health care financial managers need to consider and monitor intangible assets that have an impact on the organization’s bottom line. These include clinical processes, staff skills, and patient satisfaction and loyalty. The BSC is an integrative approach to performance evaluation that examines performance related to finance, human resources, internal processes, and customers (Oliveira, 2001 ). The BSC is more than a measurement tool; it is a management system used to achieve long-term strategic goals by linking performance to outcomes and can be used to (1) guide current performance through feedback and (2) target future performance improvement. The instrumentation of a BSC focuses on a single strategy where multiple, relevant measures are linked together in a cause–effect network. Measures transcend the traditional financial accounting framework used to assess organizational performance, seeking to build internal assets and capabilities while forging the integration of strategic alliances. Leading (structure and process) and lagging (outcomes) measures are identified in four categories: financial performance, customer knowledge, internal business processes, and staff learning and growth. Customer satisfaction is typically included in the customer knowledge category. Indicators are selected by a designated group within an organization, and periodic reports are disseminated for monitoring and evaluative purposes.

Application of this innovative tool is occurring with greater frequency in health care (Hall et al., 2003 ; Pineno, 2002 ; Pink et al., 2001 ). Several major integrated delivery and hospital systems are currently implementing BSCs. Macdonald ( 1998 ) reported on the application of the BSC in aligning strategy and performance in long-term care at the Sisters of Charity of Ottawa Health Service. The section of their developed BSC addressing customer satisfaction is shown in Table 6–2 .

TABLE 6–2 A Balanced Scorecard Example

Strategic Objective	Lag indicators	Lead indicators
Meet clients’ needs, priorities, and expectations in a manner that exemplilfies the Sisters of Charity of Ottawa Health Service values of respect, compassion, social justice, and community spirit.	· • Overall satisfaction—clients and families (all programs) · • Satisfaction with physical, social, emotional, and spiritual care (all programs) · • Percentage of patients satisfied with service in the language of their choice (all programs) · • Percentage of patients who feel they are treated with respect; participate in decisions about their own care (all programs)	· • Volunteer hours priorities, and per patient day (percentage variance) (Human Resources) · • Direct care hours worked per patient day (percentage variance) (Finance) · • Staff stability ratio (Human Resources) · • Number and nature of projects that focus on increasing patient, resident, or client quality of life (all programs and departments)

Source: Excerpted from Macdonald, 1998.

CASE-MIX ADJUSTMENT: ADDRESSING A SPECIAL ISSUE IN MEASURING CONSUMER SATISFACTION

Using performance measures to suggest improvement opportunities as part of CQI often results in internal staff criticism such as “my patients are sicker” or “my patients are different.” Case-mix adjustment methodologies have been used to control for explainable differences in subpopulations of patients-enrollees so that valid comparisons may be made with adjusted performance measures. Case-mix and risk adjustment techniques are a common feature of the computer macros that estimate HCAHPS measures and are used to adjust consumer ratings and composites to allow for cross-plan comparisons (Landon et al., 2004 ). The HCAHPS comparison’s case mix adjusts for consumer characteristics such as age, gender, education, self-reported health status, and proxy respondent.

Hargraves and colleagues ( 2001 ) examined patient characteristics thought to be associated with reports and ratings of hospital care and considered these as adjusters to hospital ratings and reports. Demographic and health status variables were evaluated by exploring how adjusting reports and ratings for hospital differences in such variables affects comparison of performance among hospitals. Their findings suggest that the demographic variables with the strongest and most consistent associations with patient-reported problems were age and reported health status. Patient gender and education sometimes predicted reports and ratings but not as consistently as the other two variables. However, overall, the impact of adjusting for patient characteristics on hospital rankings was small. Nevertheless, the authors recommend adjusting for the most important predictors, such as age and health status, to help alleviate concerns about bias. As with the earlier study, the authors also recommend that data be stratified by groups of patients (i.e., medical, surgical, obstetrics) to facilitate interpretation and target quality improvement efforts.

CONCLUSIONS

Patient satisfaction surveys are used increasingly to gauge consumer experience with health care. However, efforts to adequately measure consumer satisfaction are complex. As with any evaluative (whether formative or summative) effort, consideration must be given to the ultimate end use of the generated satisfaction measures. In doing so, key measures should be selected given the context of the particular health care service and/or procedure. Relevant consumers should next be identified and their input solicited. Assessment should be made of alternative modalities for gathering data from consumers. It is important that this choice be aligned with the intended use of this information in light of organizational constraints on resources, time, and internal capabilities. Then the collected satisfaction measures should be applied as part of the CQI process, and always with the goal of taking action to improve quality and safety.

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