How does Ms. W. from Düsseldorf choose the clinic if she needs a new hip joint? Until recently there was only one answer to this question. She was referred by her local orthopedic surgeon and may have relied on information she knew from hearsay. The question of what information the treating doctor relied on remained open. How can you assess the quality of a clinic? How can Ms. W. get information other than asking relatives, friends and acquaintances? Occasionally there are special issues of relevant magazines that publish ranking lists of the supposedly “best hospitals in Germany”. However, the methods underlying these lists are usually incomprehensible and who knows which is the best hospital for Ms. W. given her personal experiences and preferences?
> The internet platform www.weisse-liste.de has been offering guidance since June 2008. Together with the professional associations of the largest consumer and patient organizations, the Bertelsmann Foundation offers independent information about hospitals through the Weisse Liste internet portal. The information basis is the legally required structured quality reports. These are supplemented by patient experiences. Recommendations and assessments from patients can influence the decision for or against a hospital more than data on case numbers and treatment results.
All clinics in Germany survey their patients using a uniform, reliable and validated instrument at regular intervals and using the same procedure. The results are compiled and published by a central and independent body. Patients can quickly, clearly and conveniently get an idea of what experiences other patients with similar illnesses have had in the various hospitals and specialist departments.
importance increases
In addition to clinical key figures such as case numbers, care ratios, infection rates or quality assurance key figures (BQS), patient experiences are becoming increasingly important. The battle between supposedly “objective” clinical endpoints and “subjective,” “soft” survey data has now been resolved. Nobody seriously thinks anymore that medical care facilities can only be validly recorded and assessed with one type of data. For example, the number of unnecessary operations is just as important and relevant as the fact that medical staff inform patients well and allow patients to participate in key decisions.
Is the vision feasible?
Patient reported outcomes have recently become increasingly important, even in clinical studies. They are used to determine the benefits of new treatment procedures or the approval of medications. But they are hardly patient- and user-friendly because they are difficult to understand and cannot be compared. The abundance of different instruments, the often poor methodological quality, inconsistent survey standards and the refusal of many institutions to publish the results currently represent hurdles that appear to be insurmountable.
The operators of the White List, together with various organizations such as the Swiss association Outcome, have developed the Patients' Experience Questionnaire (PEQ) and thus answered the question about the realization of the vision with “yes”. With just 15 questions (or three additional questions for women who have given birth), the short questionnaire records patients' experiences in acute inpatient care and covers all the content relevant to assessing the quality of care from the patient's perspective. The following characteristics are requested:
• Relationship with doctor/nurse
• Information from doctor/nursing staff
• Organization and management
• Service
• Professional expertise of the doctor or nursing staff
• Treatment success
• Willingness to recommend
It would be presumptuous to think that all clinics could be banned from carrying out their own surveys overnight and forced to use a uniform instrument like PEQ. This would not only mean the sudden end of trend data that has often been built up over years, it would also be a significant intervention in the market for patient survey providers. It therefore quickly became clear to the initiators of PEQ that it could only be an instrument that could be used as a “piggyback solution” on top of the existing surveys.
This resulted in the most important methodological requirements for PEQ, such as:
• Can be used across indications (generic),
• short,
• can be used as an add-on to existing instruments,
• relevant for quality management as well
• is psychometrically tested, capable of differentiation and sensitive to change and
• should have a high level of acceptance among users.
An interdisciplinary working group has been developing the Patients' Experience Questionnaire (PEQ) since 2006. All measurements and validations have been completed since the beginning of 2008. PEQ is already used for measurements in Switzerland and it has been clear since February 2009 that PEQ is regularly used in the measurements of the Outcome association in Switzerland.
In Germany there is still no national organization that regularly uses the PEQ in its measurements. However, the methodological requirements have already been created. PEQ is already used by many hospitals as part of their internal quality management. In order to publish the PEQ results, the clinics must work with an accredited survey institute (see www.weisse-liste.de/PEQ). Only if the methodological standards are adhered to is a fair, undistorted comparison of the results possible. And the public comparability of patient experiences is the goal that PEQ strives for. That's why the results can be published not only in the White List, but also in all other portals or publications.
The first results can already be seen in the white list. Recommendations to use PEQ in clinics and to publish results have already been made by the Evangelical Hospital Association of Germany and the Catholic Hospital Association.
The PEQ was developed and validated over a two-year process by an interdisciplinary working group with Swiss and German participants. The detailed development and validation process is described in the book “Making patient experiences comparable” (in print). Patients were involved in every development phase to ensure the understandability, relevance and clarity of the questions. Only the essential steps will be presented here.
Validation result
The PEQ is an instrument that can be added to existing surveys without affecting the results of this survey. The integrated items, which combine several questions from one area, do not create the impression of redundancy with add-on procedures. The tests also showed that the previous questionnaire had no (measurable) effect on the results of the PEQ. This means that regardless of which questionnaire is used as a basis, or even when used alone, the PEQ delivers comparable results.
Thanks to its 15 questions (see www.m-vf.de), it takes very little time to fill out. With the only further development, PEQ-Birth, three additional questions inquire about the care provided by midwives. In comparison to other instruments, this is also a short questionnaire.
PEQ can be used in many clinical areas and is easy to understand for patients. The PEQ shows very sensitively differences between institutions. However, these refer to larger dimensions (“tracers”; e.g. patient-care interaction). The goals and results of the different development and validation steps are summarized in a table that can be viewed at www.m-vf.de.
Current status
The PEQ is available free of charge to interested healthcare facilities in Germany. The license rights for the Swiss version are held by the Outcome association. Instead of paying a license fee, users in Germany undertake to carry out the surveys according to clearly defined methodological rules (ensuring implementation objectivity). For publication, the data can be delivered in aggregated and anonymized form via a survey institute to the White List data collection point. The declared goal of the PEQ is to publish as many patient experiences as possible and to ensure comprehensive comparability and transparency of the results - especially for users. Currently, 50 hospitals in Germany and 24 in Switzerland have already taken part in a PEQ survey with various departments. In addition to the High German version, a Swiss German, a French and an Italian version of the instrument are in use. The initial skepticism is giving way to the increasing conviction that PEQ is a process that will prevail.
Anyone who has been well informed, treated and cared for in the hospital is happy to pass on their positive experiences to others. <<
from: Dr. Fülöp Scheibler/
Gaby Schütte*
