Validation of the Health Care Communication Questionnaire (HCCQ) to measure outpatients’ experience of communication with hospital staff
Introduction
Consumer demand for healthcare providers to adopt higher standards of communication skills has become a leitmotiv within the framework of “patient-centeredness” [1], [2], [3]. Patient-centered skills, which are responsive to patients’ values, needs, and preferences, involve relationship, partnering, counselling, and communication [4], [5]. Among these skills, patient-centered communication (PCC) has been recognised as integral to effective healthcare and positively affecting patients’ satisfaction, adherence, and health [6], [7], [8], [9].
PCC has been defined as the array of communicative behaviours that can enhance the quality of health provider–patient relationship [10] by means of lowering uncertainty and ambiguity in healthcare settings [11]. Furthermore, given the patients’ inability to evaluate medical procedures, they evaluate their experience based on communication skills of the healthcare professionals [12].
Communication behaviours related to patient satisfaction may include: clear and direct way to communicate [13], empathy and friendliness [10], nonverbal affiliative expressiveness [14], listening [11], [15], and other basic skills such as courtesy [16]. Patients visiting a healthcare facility may encounter a number of professionals other than doctors who may influence the quality of their experience [17]: allied health professionals (i.e. laboratory or radiology technicians, medical assistants, etc.) and the clerical/administrative support staff (i.e. patient service receptionists, information desk personnel, etc.). All these professionals and workers are allies, working together to make the healthcare system function. The substantial correlations found between staff, nurses, and physicians indicate that PCC skills are equally relevant and applicable to all healthcare workers, who should be aware of the hospital quality standards [18]. Accordingly, the accreditation system demands that all of them contribute to the delivery of quality care by means of acquiring effective communication skills [19].
Nevertheless, most of the reports focus on doctors’ communication, while the performance of the rest of the staff is a much-neglected sector of health system analysis [19].
In Italy, the general hospitals offering inpatient care are also required to provide services to outpatients through a separate administrative care provision. There is a growing interest for the quality of such settings as evaluated by outpatients, taking into account the reduction in inpatient days, and the substantial rise in hospital outpatient activity which has occurred in recent years [20]. This concern is common to other countries of the Mediterranean area with similar healthcare systems [21]. Experience of outpatient care is also a key factor in determining a hospital's reputation with the public [21], [22].
Patients’ opinion of quality of healthcare is a multidimensional subjective indicator that cannot be understood only by observing care directly [23]. Patients’ assessment has clear advantages, in terms of cost and practicability, revealed in the extensive use of surveys to measure patient satisfaction and experiences [24].
Patients’ satisfaction measures, the most traditional way of collecting patients’ view on healthcare performance, have been criticised for methodological problems of validity, reliability, and power to discriminate between satisfactory and non-satisfactory experiences [24], [25], [26], [27]. For example, such surveys typically elicit overwhelmingly positive ratings which do not reflect the patient's real experience. Furthermore, most of these instruments are generic and unable to identify human versus technical dimensions [28], [29], [30], [31], [32].
To our knowledge, a recent instrument with satisfactory validity and reliability, measuring outpatients’ satisfaction with hospital care, has been developed by Gasquet et al. [33] involving patient representatives in the creation of individual items. It is a 27-item, 4-subscale questionnaire measuring appointment making, reception facilities, waiting time, and doctor consultation. Nevertheless, consistent with the majority of patient satisfaction questionnaires [24], consultation with the doctor represents half the items, while quality of communication is limited to information provided by the doctor.
The Picker Institute argues that, given the holistic nature of patient-centered care, patient satisfaction is not a sufficiently broad outcome measurement [22].
As an alternative, surveys of experiences have been developed as indirect measures of patients’ satisfaction that allow more objective information about the occurrence of specific events to be collected patients are asked to report on their experience of a particular provider at a specific point in time, and responses are intended to be factual rather than evaluative [22], [34].
Although the investigation on patient experiences has also been criticised for methodological problems [22], [35], [36], questionnaires recently used in large-scale studies were found to have good reliability and validity. One example is the Patient Experiences Questionnaire (PEQ), a 35-item, 10-scale instrument based on factor analysis [37]. Nevertheless, attention given to communication is limited to information provided by doctors and nurses, non-medical hospital staffs are not taken into consideration, and the targets of investigation are inpatients.
Among the questionnaires measuring patient experience recently reviewed [22], the Consumer Assessment of Health Providers and Services (CAHPS) emerged as the most widely used family of tests with the strongest overall characteristics in terms of content, development and testing [38]. CAHPS surveys ask about dimensions of care like provider communication skills, access to care, helpfulness of office staff, courtesy, and respect. Among these, the hospital survey asks inpatients about their recent experiences in specialized wards, including those with nurses and doctors communication behaviours. Another CAHPS instrument (ECHO) includes a few supplemental items on office staff communication behaviours such as courtesy, respect, and helpfulness. CAHPS instruments are the most comprehensive measures available that also include items addressing the communication domain. Although these items are generic in content, usually targeted at measuring inpatients’ experience, and concerned mostly with doctors and nurses skills, they served as a point of reference for generation of items in the present study.
Our analysis of the literature on measures of patients’ experience with PCC in healthcare lead to the conclusion that there is a need to develop and test a new questionnaire addressing the specific object of our investigation. At the moment, there is a lack of brief tools, adequately validated in the particular setting of outpatient hospital care, specifically assessing the quality of communication skills of allied health professionals and administrative staff from the patients’ perspective.
Although most of the questionnaires measure inpatients’ perception of quality of health care, we believe that also the view of outpatients who attend the hospital facilities occasionally and for a brief period of time is relevant and useful.
The aims of the current paper were/are to describe the development of the Health Care Communication Questionnaire (HCCQ) in order to measure outpatients’ experience with PCC of non-medical hospital staff, and to evaluate its reliability and factorial validity, using confirmatory factor analysis.
Section snippets
Development of the questionnaire
The questionnaire development followed three phases: (1) identification of domains and items of relevance; (2) confirmatory factor analysis to verify items dimensionality and assess factorial validity; (3) assessing reliability of the scales.
Outpatients and hospital workers were involved in identification of core dimensions and in creation and selection of items to be included in the questionnaire. Some items of existing instruments were also taken into consideration as examples [38].
Hospital
Results
Analysis of the HCCQ individual items indicated that item scores were not skewed versus approval; actually, they did not show a ceiling effect, none of them showing extreme means and close to zero variances. Item means ranged between 3.46 and 4.02, variances between 0.42 and 0.92. Skewness, a measure of the asymmetry of the frequency distribution, ranged between −0.64 and −0.05, and kurtosis, the degree of peakedness of the distribution, ranged between −0.04 and 0.98. Skewness and kurtosis
Discussion
The creation strategy of the HCCQ follows the recommendations for “good practice” in validation of measures of patient experience of healthcare [26]. The role given to patients in the early development stage helped to ensure internal validity as regards identification of content and readability of item formulation [24].
The high response rates (90%) expressed a patient's positive attitude to answer the questionnaire immediately after interaction. The questionnaire answer scores were not skewed
Acknowledgements
The authors thank all members of the discussion groups and declare that they have no competing interests.
References (61)
- et al.
Measuring patient-centeredness: a comparison of three observation-based instruments
Pat Educ Couns
(2000) - et al.
Patient-centred consultations and outcomes in primary care: a review of the literature
Pat Educ Couns
(2002) - et al.
Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels
Soc Sci Med
(1988) How valid and reliable are patient satisfaction data? An analysis of 195 studies
Int J Qual Health Care
(1999)Capturing what matters to patients when they evaluate their hospital care
Qual Saf Health Care
(2002)Patient satisfaction: a valid concept?
Soc Sci Med
(1994)- et al.
The OutPatient Experiences Questionnaire (OPEQ): data quality, reliability, and validity in patients attending 52 Norwegian hospitals
Qual Saf Health Care
(2005) American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians–American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter
Ann Intern Med
(2002)- et al.
Anger, aggressiveness, and coronary heart disease: an interpersonal perspective on personality, emotion, and health
J Pers
(2004) The quality of care. How can it be assessed?
J Am Med Assoc
(1988)