Keywords
Patient Experience, Patient Feedback, Healthcare Improvement, Quality of Health Care, Rehabilitation, Methodology, Scoping Review
Patient experience is routinely collected in the clinical environment in many different ways throughout various person-provider encounters, but so far limited research focused on understanding the methods of using it to improve the quality of healthcare. This paper presents a protocol for a methodological scoping review examining the methods of obtaining, analysing, reporting, and using patient experience data for quality improvement in rehabilitation settings.
The scoping review will be conducted according to the guidelines from the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the methodological framework by Arksey & O’Malley. A comprehensive search of the literature will be performed using a three-step search strategy: an initial limited search of two databases was already performed and helped to identified relevant key words and index terms. The developed search string will be adapted and applied across four databases. This will be followed by search of the reference lists of selected sources and hand-search relevant data-hubs. Studies with a clear focus on patient experience or feedback collected or used for healthcare improvement in rehabilitation context, will be included. A data extraction framework will be developed and piloted to guide the literature screening and data charting. Qualitative content analysis will be employed to address research questions and the results will be presented – beside the descriptive format - as a map of data in chart and tabular formats.
This scoping review will show the extent and scope of the literature on the applied methods of collecting, communicating, and using patient experience for quality improvement in post-acute rehabilitation settings and will evaluate and map the evidence on these topics. The findings will inform a research project entitled “An exploration into the use of patient experience to inform improvement in a National Rehabilitation Hospital”.
Patient Experience, Patient Feedback, Healthcare Improvement, Quality of Health Care, Rehabilitation, Methodology, Scoping Review
In response to reviewer comments and suggestions, three key modifications have been made to the manuscript. Firstly, to enhance clarity regarding the study's objectives, we have expanded the aim of the study section to list three distinct objectives aimed at mapping the literature and identifying gaps. Secondly, in order to provide a clearer understanding of the planned data analysis, we have revised the 'Stage 5: Collating, summarising, and reporting the results' section of the Methods, outlining comprehensive plans for analysing patient experience feedback in rehabilitation settings using techniques such as descriptive mapping, frequency counts, narrative synthesis, qualitative content analysis, basic coding, and categorization methods, while excluding evidence synthesis due to the scoping review's scope. Finally, we have provided more detailed justification for focusing on post-acute rehabilitation as a crucial phase for rehabilitation patients after the acute stage of their rehabilitation journey; and aligning it with the focus of a research project conducted in a post-acute rehabilitation hospital.
See the authors' detailed response to the review by Abubeker Alebachew Seid
See the authors' detailed response to the review by Bronwyn Simpson
Patient experience is an important feature of patient-centred care; interest in which has been increasing in recent years. Patient-centred care has been valued as a means to enhance quality of care in healthcare settings (Richards et al., 2015) The aim of patient-centred care is to effectively address the needs and values of the patient by focusing on including the patient in the decision-making process (Cheng et al., 2016). The provision of patient-centred care has had a positive impact on patient satisfaction and self-management or self-care practices (Rathert et al., 2013). Additionally, patient-centred care has been found to be comparable or superior to physician- or disease-centred care (Morgan & Yoder, 2012; Rathert et al., 2013). In 2015, the World Health Organization published a global strategy on integrated people-centred health services (IPCHS) which highlighted the importance of people- and patient-centred care for improving access to and satisfaction with care, improved health and clinical outcomes, and improved health literacy (World Health Organization, 2015).
Patient experience encompasses the wide variety of interactions that a patient has within the healthcare system, as well as the patient’s satisfaction with these interactions. Incorporating patient experience into healthcare provision and research has been shown to improve clinical safety and effectiveness (Doyle et al., 2013), as it allows for the identification of strengths and shortcomings in current services. By understanding patient experience, healthcare systems have the opportunity to implement change and potentially improve services based directly on feedback from the people they intend to serve and avoids prescribing what is assumed to be valuable. There has been a significant increase in research regarding Patient and Public Involvement (PPI) (Brett et al., 2014). PPI entails working in collaboration or partnership with patients, carers, service users or the public in planning, designing, managing, conducting, dissemination and translation of research (Stewart et al., 2011). By involving patient experience in the improvement of services, it may be possible to create care experiences that are not only effective but personally meaningful to patients. The collection of patient experience data offers a different, non-clinical perspective on the operation of healthcare systems and is thus an essential consideration in the improvement of healthcare delivery.
Collection of patient experience data is unlikely to solely lead to significant changes in clinical practice (Ahmed et al., 2014). Though opportunities to give feedback are regularly offered to patients across many health disciplines (for example, the National Patient Experience Survey which commenced in 2017) (Health Information and Quality Authority, 2017), no change will come into effect unless this feedback is acted upon. It is the responsibility of healthcare providers to incorporate and integrate patient feedback into efforts to improve healthcare practice and service delivery. Failure to do so is unethical; it is morally incorrect to request feedback from patients if that feedback will be ignored (Coulter et al., 2014). Therefore, it is essential to not only understand how patient experience data is collected but how learnings from this data are integrated to inform change in healthcare settings.
Recent systematic reviews broadly examined this topic in healthcare. Gleeson et al. (2016) reviewed approaches to using patient experience data for quality improvement in healthcare settings. They found that patient experience data were most commonly collected by using questionnaires. These were typically administered and analysed by external organisations who offered limited support for healthcare staff to interpret and use the results. The collected patient experience data were typically used to identify minor areas of process changes that did not require major structural alterations or changes to the practice. While most studies reported having made effective improvements, the authors found it difficult to determine the actual changes or ascertain their impact. Cadel et al. (2022) reviewed studies that used patient experience data to inform quality improvement and found a wide range of quality improvement initiatives implemented in hospital settings but limited information on the process of using patient experience data and how initiatives were implemented. They concluded that there is a broad understanding in the literature that it is important to act on patient experience data, but less consensus exists on how these data should be actioned.
The authors decided to limit the present review to the field of rehabilitation because it is being undertaken to inform a research project conducted in a post-acute rehabilitation hospital. Specifically focusing on post-acute rehabilitation patients within this context allows for a targeted exploration of their unique experiences and needs. Rehabilitation patients more often live with chronic impairments, co-morbidities, and face more complex problems, in consequence receiving care for a longer period of time and meeting a larger number and variety of healthcare professionals. Additionally, present study examines post-acute rehabilitation as a crucial phase in patient care after the acute stage. It is especially important therefore to capture and learn from the perceptions and experiences across various components of received care to ensure the quality of the person-centred care in rehabilitation.
A recently published scoping review examined the use of patient experience feedback for person-centred rehabilitation quality improvement (Jesus et al., 2022). It focused on the outcomes and included papers that contained an analysis of the impact of the quality improvement informed by patient experience data. They identified only a few examples of the use of patient experience feedback in quality improvement or codesign activities in the rehabilitation literature. They also found that these patient experience improvement activities relied exclusively on retrospective experience survey data, not making use of more actionable, real-time, and inclusive forms of patient experience feedback. The authors of the present review consulted the lead author in the preparation of the current protocol to discuss remaining gaps in the current evidence synthesis. The team made the decision to focus on the process of collection and usage of patient experience feedback. Therefore, the aim of the current scoping review is to examine the methods of obtaining, analysing, reporting, and using patient experience data to inform quality improvement in post-acute rehabilitation settings.
A scoping review is described as “a type of evidence synthesis that aims to systematically identify and map the breadth of evidence available on a particular topic, field, concept, or issue (…) within or across particular contexts.” (Munn et al., 2022)
The protocol for this scoping review was developed under the methodological guidance of Levac et al. (2010) and the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis guidelines (Peters et al., 2020). As outlined in Arksey and O’Malley (2005), the scoping reviews often contain iterative processes, and the researchers potentially may need to revisit previous stages in the light of newly acquired knowledge. These changes to the protocol will be reported in the final paper, which will be composed in accordance with the Preferred reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).
The methodological framework by Arksey and O’Malley consists of six stages: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting/mapping the data, (5) collating, summarising, and reporting results and (6) expert consultation. The framework will be guiding this review protocol and the subsequent scoping review.
The authors received ethical approval for conducting the scoping review from NRH Research Ethics Committee (date of approval 24/05/2022) and the UCD Office of Research Ethics (Research Ethics Exemption Reference Number LS-E-22-06-Carroll, date of approval 13/01/22).
Following the PRISMA-ScR guidelines, the Population, Concept, Context (PCC) framework was used to guide the framing of the research question and key screening criteria.
Population: patients, clients, or users of healthcare services
Concept: the process of collecting, analysing, reporting, and using patient experience, satisfaction, or feedback for the improvement of quality of health care
Context: studies conducted in rehabilitation healthcare settings: rehabilitation hospitals, centres, clinics, long-term care facilities or out-patient services in any country.
Based on the above, the following research question was identified:
How are patient experience data collected, analysed, reported and used for healthcare improvement within a rehabilitation setting?
Our objectives were:
1. To explore and categorize the diverse methodologies employed for collecting patient experience data in post-acute rehabilitation settings, assess their implementation, and investigate their impact on improving patient care internationally.
2. To determine the extent and scope of existing literature related to the applied methods of collecting, communicating, and utilizing patient experience data for quality improvement in post-acute rehabilitation settings.
3. To identify and highlight gaps in the current literature pertaining to the methods used for collecting patient experience data in post-acute rehabilitation settings.
Following the recommendation by the JBI Manual for Evidence Synthesis (Peters et al., 2020), a three-step process will be used to carry out the search. Step 1 – a preliminary search for relevant articles on two online databases – has already been performed, followed by an analysis of the titles, abstracts, and index terms of the retrieved papers to identify the relevant key terms and phrases. Step 2 will involve the search using the identified key words (as outlined in Table 1) across the included databases. In Step 3, reference lists of selected sources will be manually searched to identify any additional relevant studies. In addition, we will compile a list of measures and instruments widely used for capturing patients’ feedback and perform a search for these applied in rehabilitation settings to find studies relevant to our review.
A comprehensive search of the literature will be undertaken within the following databases:
OVID MEDLINE
CINAHL Nursing and Allied Health (CINAHL Plus)
APA PsycINFO
COCHRANE Database of Systematic Reviews
Grey literature search will be also performed in a range of healthcare-related evidence sources and data-hubs including Lenus, greynet.org and Google.
Key search terms and search strings. The key search concepts for this review are ‘Patient experience’, ‘Healthcare improvement’ and ‘Rehabilitation setting’. Keywords, together with synonyms, alternative and related terms will be used to build a search string, and exclusion terms will be added to eliminate results linked to acute medical rehabilitation and substance abuse rehabilitation. Table 1 contains the search terms and exclusion terms for the search strings.
The search query was built from the identified key terms, and adapted for each database using Boolean operators, proximity operators, truncation markers, and applicable MeSH-, subject- and index terms and headings. An expert university librarian was consulted for designing the search strategy. Table 2 contains the search strings for each database.
Inclusion/exclusion criteria. Following the PRISMA-ScR guidelines, the Population, Concept, Context (PCC) framework was used to guide the framing of the research question and key screening criteria. In line with the methodological guidance from Arksey and O’Malley (2005), the final inclusion and exclusion criteria will be refined based on increasing familiarity with the body of literature and type of data available.
All peer-reviewed and non-peer-reviewed articles and reports published in the English language, with a focus on patient experience or feedback in rehabilitation setting, will be considered for inclusion in the review. Studies with a clear focus on patient experience or feedback collected or used for healthcare improvement, conducted within a rehabilitation setting or with relevance to a rehabilitation context will be included. Articles describing collecting patient feedback or testing survey instruments will not be included unless they also include a specific focus on using the collected data for healthcare improvement. Articles will be excluded if they contain no discussion of using patient experience or user satisfaction for the improvement of quality of healthcare and/or are unrelated to rehabilitation settings. As formal assessment of methodological quality of the included studies is not required for scoping reviews, appraisal of the methodological quality will not be performed.
Careful consideration was given to the timeframe of the search strategy and the authors decided to limit the search to the previous ten years of evidence, in order to keep focus on recent findings and relevant contexts.
Before the start of the screening, the team of reviewers will meet to decide on study inclusion and exclusion criteria. All abstracts will be screened by two reviewers and a third reviewer will resolve any conflict and decide on final inclusion. The articles found from the database searches will be imported into the bibliographic reference management software Endnote. Duplicate articles will be removed. The Covidence systematic review software tool will be used for screening of the retrieved literature. Free tools, such as Rayyan, can also be used as an alternative. The reviewers will meet at the beginning, midpoint, and final stages of each review process. At the first meeting, study inclusion and exclusion criteria will be decided on. The reviewers will independently screen 25 titles/abstracts that were randomly selected for the pilot testing process (in accordance with the JBI Manual for Evidence Synthesis), and then meet to discuss the differences and modify the inclusion criteria, if needed. The screening will start when 75% (or greater) agreement is achieved. All abstracts will be screened by two reviewers and a third reviewer will resolve any conflict and decide on final inclusion.
Potentially relevant papers will be retrieved in full and imported into Covidence systematic review software. The full text article review will be undertaken by the same reviewers using the same method, piloting first the screening process on a sample of randomly selected papers. The full text of selected articles will be assessed against the inclusion criteria by two reviewers. Reasons for exclusion of sources that do not meet the inclusion criteria will be documented and reported in the scoping review. Any disagreement will be resolved by a third reviewer.
A provisional data charting table, for extracting relevant data from sources deemed eligible for inclusion, will be developed and piloted by the review team at the protocol stage, in line with the JBI Manual for Evidence Synthesis (Peters et al., 2020).
The following types of information will be extracted:
Author(s)
Year of publication
Journal information
Origin/country of origin
Research design and methodology
Study setting (hospital / community)
Population characteristics (sample size, patients & family attributes)
Definition/description of patient experience
Type of patient experience measure or feedback used
Methods of patient experience data collection (including timepoint and by whom is the patient experience data collected)
How patient experience data is used for healthcare improvement
Healthcare improvement characteristics (improvement initiatives, description, content, method of delivery, frequency, duration)
Key findings
Interpretation of the findings
Recommendations for future research, policy, or practice
A small sample of publications (n=10) will be randomly selected to pilot the data charting table, then the reviewers will meet to ascertain accuracy and consistency and discuss the discrepancies. It is anticipated that data charting will be an iterative and reflexive process and consequently the data chart will be refined throughout the data extraction stage.
The PRISMA-ScR guidelines (Tricco et al., 2018) will be used to report the findings and a PRISMA flow diagram will be created to report the details of the screening and selection process. As per JBI guidance, the extracted data will be presented in tabular and/or diagrammatic form in a manner that aligns with the objective of this scoping review. The extracted results will be descriptively mapped to provide an overview of the various methods employed in the collection and utilization of patient experience feedback in rehabilitation settings. Simple frequency counts covering key concepts, methods, or attributes will be carried out to demonstrate the general characteristics of the included studies, and a narrative synthesis approach will be utilized to answer the research questions. Descriptive qualitative content analysis will be employed to gain a deeper understanding of the methods used in obtaining, analysing, reporting, and utilizing patient experience data. Evidence synthesis will not be performed, as this would be beyond the scope of a scoping review (Peters et al., 2020). Basic coding and categorization methods will be systematically employed to analyse and label extracted data, identifying recurring themes and patterns relevant to the methods of obtaining, analysing, reporting, and utilizing patient experience data. This process will allow to assess the completeness of information within each category, aligning findings with research questions, and ultimately identifying areas in which a literature gap exists.
This scoping review is being undertaken to inform a research project entitled “An exploration into the use of patient experience to inform improvement in a National Rehabilitation Hospital,” which will investigate the methods of collection and subsequent implementation of patient experience data in a post-acute rehabilitation setting. The findings of this project will be disseminated to key experts and stakeholders within the National Rehabilitation Hospital (NRH). The review will be submitted for publication in a peer reviewed academic journal, and the results will be presented at conferences.
Expert consultation - the optional, but recommended stage of the methodological framework by Arksey and O’Malley (Daudt et al., 2013) is going to be embedded throughout the whole review process. Professional stakeholders (i.e., health and social care professionals, managers) were consulted to identify priorities and consequently to help guide the research question and design. Throughout the course of the scoping review, expert stakeholders will be engaged in consultation to obtain recommendations for the types of data extracted and the presentation of findings, in order to shape the direction of the scoping review so it will support the research project as closely as possible.
Step 1 of the three-step process for applying a search strategy (Peters et al., 2020) has already been completed. A preliminary search for relevant articles has been performed. The titles, abstracts, and index terms of the retrieved papers were analysed to identify the relevant key terms and phrases. Search queries were built and adapted for each database based on the identified terms. The search queries were tested and are ready to be run.
This scoping review will address a gap in the current evidence synthesis by exploring the methodologies employed to collect patient experience data and how it is implemented within post-acute rehabilitation settings to improve patient care internationally. The findings from this review, as outlined in the current protocol, will highlight the extent and scope of the literature on the topic of using patient experience to improve healthcare delivery in rehabilitation settings. Additionally, the review will map the research on the applied methods of obtaining, analysing, reporting, and using patient experience for quality improvement, as well as an evaluation of the methods employed. While the impetus for this review is to inform a research project (“An exploration into the use of patient experience to inform improvement in a National Rehabilitation Hospital”), the review may be applied to other clinical settings and offer an opportunity for researchers and healthcare providers to reflect on methods used to gather patient experience data in various clinical settings.
The authors are grateful to the NRH Foundation and the UCD Foundation for funding the INSPIRE-NRH project that includes the present scoping review.
The authors are grateful to Tiago S. Jesus, OTD, PhD, Northwestern University, USA for the assistance in shaping the scope of the review.
Is the rationale for, and objectives of, the study clearly described?
Partly
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Competing Interests: No competing interests were disclosed.
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Evidence synthesis
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Physiotherapy and rehabilitation, Musculoskeletal disorders, Systematic review and meta analysis
Is the rationale for, and objectives of, the study clearly described?
Partly
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Not applicable
References
1. Grover S, Fitzpatrick A, Azim FT, Ariza-Vega P, et al.: Defining and implementing patient-centered care: An umbrella review.Patient Educ Couns. 2022; 105 (7): 1679-1688 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Health services research
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Physiotherapy and rehabilitation, Musculoskeletal disorders, Systematic review and meta analysis
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Qualitative research, scoping reviews, case study research in the field of disability-related inclusion and well-being.
Alongside their report, reviewers assign a status to the article:
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Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
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