AUTHOR(s): Koska, Mary T. TITLE(s): Surveying customer needs, not satisfaction, is crucial to CQI. (continuous quality improvement; includes related article) illustration photograph Summary: Hospital quality control can be improved by using more exacting tools for gathering information. For example, open-ended survey questions geared to a particular department are more useful than yes/no-type questions. Dialog with physicians and staff is helpful in measuring service quality in technical areas. A number of innovations are improving quality control, such as portable computers that allow patients to register evaluations day or night. The data can then be analyzed according to such factors as time registered or the gender of the patient. Hospitals p50(3) Nov 5 1992 v66 n21 Understanding the differences between customer needs and customer satisfaction is crucial to hospitals' success in quality management, says an expert from the University of Wisconsin Hospitals (UWH), Madison. To support his point, David Gustafson, Ph.D., professor of industrial engineering and preventive medicine at UWH, refers to a study of organizations with quality improvement programs, published in an April issue of The Economist. Some of the CQI programs studied were successful, but two-thirds were not. The key finding of the article, he says, was that the extent to which an organization maintains a customer focus determines the difference between quality efforts that fail and quality efforts that succeed. For hospitals, this means taking a second look at how they collect data on customer needs. "The typical patient satisfaction survey--how do you like our doctors, our nurses, our food--doesn't get a customer needs at all," he says. Survey instruments must provide specific information on what customers need in order to chart process improvement plans that meet the goals of TQM and CQI. Breast cancer fears. UWH applied this focus on customer needs to a survey of 400 breast cancer patients, their partners and their adult children. The questions were directed to reveal specific needs (see figure). The survey results indicated that patients needed to access information quickly and communicate with other breast cancer patients privately. As a result of the survey, 80 percent of the women who were diagnosed with breast cancer at UWH now take home a computer that enables them to write letters to other breast cancer patients, access a library of articles, or consult a list of 250 commonly asked questions about the disease. The success of the computer-lending program exemplifies the difference between surveying customer needs vs. surveying customer satisfaction, says Gustafson. Another example: After interviewing UWH patients who had undergone bypass surgery, the most common comment was that patients were surprised to wake up on a ventilator. "The feeling of panic that patients expressed about that experience was tremendous. They said that no one had ever told them to expect that," Gustafson says. "So let's suppose that instead of a customer satisfaction survey that asks, 'How do you like our doctors?' the survey asks 'How well did we help you understand what it would be like when you woke up after surgery?'" Once needs are understood, hospitals can then devise a satisfaction survey that can provide baseline monitoring of how well needs are being met, he adds. Soothing pain anxiety. At HCA Wesley Medical Center, Wichita, KS, telephone conversations with discharged surgery patients revealed a common patient need that was going unmet, says Anita Dorf, Ph.D., assistant to the president for quality improvement. "Patients were thrilled to be called and had positive things to report. But almost every surgical patient said, 'I sure didn't expect the kind of pain I'm having. Who should I talk to about this?''' Dorf says. Although discharge planning included instructions on how to take oral pain medication, patient comments led the hospital to realize that the discharge process didn't describe the degree of relief that oral pain medication provided compared with the relief provided by intravenous pain medication received in the hospital. Once that information began to be included in discharge instructions, patient anxiety and comments on postdischarge pain fell dramatically, she says. Voice of the customer. These examples illustrate how hospitals must be ready to integrate the "voice of the process" with the "voice of the customer" in order to truly improve work processes under CQI, says John Riley, vice president, total quality management at Sutter Health, Sacramento, CA. Riley credits the book Deming's Road to Continual Improvement, by William W. Scherkenbach, for this philosophy. "I don't often use the word 'paradigm,' but we truly are moving from one paradigm to another in how we look at the way we do our day-to-day work and how it meets the needs of a whole array of customers," he adds. As a result, how professionals approach needs/satisfaction data collection has changed significantly. To start, the term 'customer' no longer refers only to patients. Now that term has been expanded to include third-party payers, government regulators and internal customers such as employees and physicians. Expanding the definition of 'customer' has enabled hospitals to gain a wide-angle view of their services. "Patients understand the concepts of prompt service, friendly interactions and cleanliness, but they're not really in a position to always judge the quality of the professional services they receive," says Riley. For a patient, the hallmark of successful surgery may be simply waking up. But the patient may not be in a position to know that a surgery that was only supposed to take one hour took twice that long and therefore exposed the patient to unnecessary anesthesia, Riley says. "Now we're saying let's be talking to the physician, the staff the people who are in a position to tell us how well we're doing on quality care," he says. Reporting specific details. Linking customer-needs data to CQI process improvement requires that the customer not only give a general rating of needs but report on details that are specific enough to chart improvement plans, says Eugene C. Nelson, director of quality care research, measurement and education at Dartmouth-Hitchcock Medical Center, Lebanon, NH. "That's where specific reports [of patient experiences] can be especially valuable," Nelson says. "A report can use the patient as an observer, an anthropologist." Most customer-needs surveys ask for responses that "rate" hospital services from excellent to poor, or ask respondents to agree or disagree with a statement. Open-ended or yes/no survey questions will elicit a "report" response that can provide "fine-grained" feedback for monitoring improvements, Nelson says. Both are valuable survey methods, he adds. For example, patients can rate the speed at which they received their bill anywhere from "excellent" to "poor." Or they can report on it by answering the question "How many days after leaving the hospital did you receive your bill?" A standard survey from that takes this report approach is the Picker/Commonwealth Patient-Centered Care survey, which is available to all hospitals. In addition, Nelson finds it helpful to teach the professionals who are providing care how to do open-ended interviews, a technique that he says can be easily mastered and incorporated into their own work. Anytime, anyplace data. TQM/CQI projects that focus on department, floor, or unit processes demand flexible survey instruments that meet a number of needs. The instruments must be easily modified to target specific problems. They must be easily administered and not depend on external consultants to conduct the surveys. And interdisciplinary TQM/CQI teams that encompass all levels of employees must be able to collect and analyze customer data easily. At Hospital Corp. of America (HCA) hospitals, up-to-date computer technology meets all those requirements and makes data collection for CQI projects a snap. "You can't have a data-driven quality improvement process without a simple, reliable way to collect data," says Beth Leopold, a consultant working with HCA, Nashville, TN. Since January, approximately 20 HCA hospitals have been conducting a demonstration project with a new, computerized method of collecting onsite customer reactions to their hospital experience. The RT-2000 Measurement in a Box system--or "Q" as it is called at HCA--is a freestanding, portable computer capable of reading and analyzing customer needs assessment survey cards. For approximately $10,000 in first-year start-up costs, hospitals can collect immediate customer ratings and reports at "anytime, anyplace" in the hospital or outpatient setting. For example, a hospital wishing to assess patient needs/satisfaction in the emergency department (ED) can use one of HCA's existing Hospital Quality Trends surveys, or modify a generic survey to fit its own interests. The "Q" can be wheeled into the ED, where patients can answer the survey by completing a data analysis card with a number 2 pencil and insert it into the "Q" on their own. The machine can provide a data analysis broken down by day, time of day, floor, day of week, respondent's gender, etc. In addition to analyzing trends and frequencies of needs, hospitals can get a minute-by-minute analysis of when service is meeting customer needs and when it is not. Using the "Q" puts data collection at the hospital unit level, says Leopold. The biggest advantage the "Q" offers hospitals is cost savings and quick access to customer information, says David McGrath, director of quality improvement resources at HCA St. Mark's Hospital, Salt Lake City. "I can write a survey myself and print it up on a photocopy machine and pass it out to patients. But then you have to hand-tabulate the data. The "Q" compiles the data quickly and has the capability of analyzing it into a pareto format or a run chart." St. Mark's used the "Q" to take a closer look at the care on its maternity floor and its general medicine floor. On a previous, hospitalwide customer survey, the maternity ward received excellent ratings, while the ratings were poorer on the general medical floor. But the survey didn't give particular reasons why the ratings occurred. Using a targeted "Q" survey, the hospital was able to continually survey patients on both floors. The on-site analysis reported differences in courtesy and friendliness that quality improvement teams will now begin to analyze, McGrath says. Other planned uses for the "Q" include helping their physicians survey their office patients, he says.