Measuring patient satisfaction with radiation therapy service delivery

40 Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2009

REGULAR ARTICLE

AbstractPatient satisfaction is an important component in the evaluation of health services

provided to patients. This study evaluates the results of a patient satisfaction survey

collected over five years in a radiation therapy department. The analysis identifies

that satisfaction has improved in almost all areas, but there is room for improvement

in others. The key findings are the importance of treating patients with courtesy and

respect and the relatively lower levels of satisfaction noted for patients treated with

palliative intent, an area of concern given these patients’ greater needs. We provide

aggregate results, identify factors that influence overall satisfaction and demonstrate

how the survey results have led to quality improvement initiatives, which in turn have

resulted in improved levels of satisfaction for patients.

RésuméLa satisfaction des patients est un élément important de l’évaluation des services de

santé qui leur sont prodigués. La présente étude permet d’évaluer les résultats d’un

sondage sur la satisfaction des patients colligé pendant plus de cinq ans dans un dé-

partement de radiothérapie. L’analyse indique que la satisfaction s’est accrue dans

presque tous les secteurs, mais qu’on peut faire mieux dans d’autres. Les principales

observations sont l’importance de traiter les patients avec courtoisie et respect et le

taux de satisfaction relativement plus faible de la part des patients traités en soins

palliatifs, ce qui est préoccupant étant donné les grands besoins de ces patients. Les

auteurs fournissent des résultats regroupés, repèrent des facteurs qui influent sur la

satisfaction globale et démontrent en quoi les résultats de l’étude ont suscité des

initiatives d’amélioration de la qualité, qui à leur tour ont relevé le taux de satisfac-

tion des patients.

atient satisfaction is well established as an important indicator ofthe quality of health services that patients receive.1 As such, it is log-ical that a system should be in place to measure patient satisfactionand to use the results of such measures to gauge and, where neces-sary, to improve service delivery.2

In cancer care there is some evidence that patient satisfaction may be lessthan optimal. In 1990, Wiggers et al. identified low levels of satisfaction withthe information provided to patients about their disease, treatment andsymptom control.3 A Canadian study by Ashbury et al. in 1998 found thatmost cancer patients experienced symptoms related to their disease and itstreatment, and that cancer patients were most likely to be dissatisfied withtreatments for their symptoms than for their cancer.4 More recently, a studyof 4,615 cancer patients in Germany found that areas of improvement existedin the handling of side effects, partnership and shared decision-making andside effects.5 Other studies have identified low satisfaction levels related toinformation received, waits for services, communication and physical sur-roundings.6-18

John French, FCAMRT MSc, CHE, is theDirector of Operations, Radiation Ther-apy and Surgical Oncology Program,British Columbia Cancer Agency – Van-couver Centre.

Colleen E. McGahan, MSc, works in Population Oncology, Surveillance &Outcomes Unit, British Columbia CancerAgency - Vancouver Centre.

Measuring patient satisfaction with radiationtherapy service delivery

by John French and Colleen McGahan

P

Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2009 41

Patient satisfaction is generally defined as either the extentto which experiences match expectations or whether an ex-perience is actually better or worse than anticipated.19Manyof the factors that influence patient satisfaction are under thecontrol of health care providers, which means that if appro-priately measured and understood, satisfaction for patientscan be improved.

Patient satisfaction is generally perceived as having severalfacets, with the five main facets defined by Wesbrook20 as:

• environmental and structural features such as the qualityand appearance of waiting areas;

• accessibility and convenience, such as timing of appoint-ments and waiting times;

• hotel services, such as quality of meals or cleanliness ofrooms;

• interpersonal relationships, such as the warmth andfriendliness of staff; and

• clinical competence of health care providers, defined bythe perceived ability of staff and the provision of ade-quate and accurate information.

In this study we describe how satisfaction is measured ona consistent basis for patients receiving radiation therapy atthe British Columbia Cancer Agency – Vancouver Centre. Thisfacility treats a full range of cancer patients from the Vancou-ver area and from Northern British Columbia. The Centretreated 3,903 courses in 2004, the year the study was initiated,and this increased to 4,134 courses in 2008, the last year forwhich data were analyzed. In 2004, the Centre had seven linearaccelerators (or units); additional units were added in 2006and 2007, bringing the total to nine by 2008. The patient pop-ulation treated on each unit varies, with some units predom-inantly treating patients with prostate cancer, others withbreast cancer and others for patients with advanced diseaserequiring palliative treatment. The major patient populationstreated on each unit are outlined in Table 1.

A satisfaction survey has been in use at the Centre since2004. After utilizing the survey for five years, it was decided toperform a more detailed statistical analysis of the availabledata with the intent of answering the following questions:

• Has the implementation of a process for measuring andimproving satisfaction actually led to an increase in pa-tient satisfaction?

• Are there any facets of satisfaction less than desirable?• Are there any key determinants of patient overall satisfac-

tion?• Are there any patient demographics that influence satis-

faction levels?

MEASURING PATIENT SATISFACTION WITH RADIATION THERAPY SERVICE DELIVERY

TABLE 1 Patient population on each treatment unit

TREATMENT UNIT PATIENT POPULATION

1 Predominantly male, radical prostate treatments2 Mostly female, breast treatments4 Predominantly male, radical prostate treatments5 Mix of radical breast and some palliative treatments6 Mostly female, breast treatments7 Mostly female, breast treatments8 Short-course palliative treatmentsA Mix of non-prostate and non-breast radical treatmentsB Mix of non-prostate and non-breast radical treatments

TABLE 2Facets of satisfaction and related survey items

FACET SURVEY QUESTION

Clinical competenceof health careproviders

Accessibility andconvenience

Interpersonal relationships

Environmental andstructural features

Overall rating

Do you think that you were given enough information aboutthe nature and extent of your illness?

Were you able to understand the information given to youabout the nature and extent of your illness?

Do you think that you were given enough information aboutyour radiation therapy treatments?

Were you able to understand the information given to youabout your radiation therapy treatments?

Do you think that you were given enough information aboutthe side effects that you might experience from your radia-tion therapy treatments?

Were you able to understand the information given to youabout the side effects that you might experience from yourradiation therapy treatments?

Were you satisfied with the help given to you to managethe side effects to your treatment?

If you had any questions or concerns about your radiationtherapy treatments, were they adequately addressed bystaff?

Were you satisfied with the information given to you aboutthe support services available to you (e.g., nutrition services,counselling services)?

Were you satisfied with the amount of time you had to waitin the centre for each of your treatment appointments?

Were you satisfied with the amount of time you had to waitin the centre each time you saw your doctor during yourcourse of radiation therapy?

Were you satisfied with the times that you were given foryour radiation therapy appointments?

Were you satisfied with the amount of time you had to waitin the centre for each of your treatment planning appoint-ments (dentistry, mould room, simulation or planning)?

Do you think the staff treated you courteously and with re-spect?

Were you satisfied with the waiting areas in the radiationtherapy department?

Overall, how satisfied were you with the services providedby the radiation therapy team (e.g., doctors, nurses, radia-tion therapists and clerks)?


Materials and methodsSurvey tool

The Radiation Therapy Patient Satisfaction Survey wasused to measure patient satisfaction. The survey was devel-oped by French in 1999 as part of a quality improvement ini-tiative14 and has been used at cancer centres throughout B.C.

The survey measures three demographic variables: age,gender and level of education. It has 15 measures of satisfac-tion, across four of the facets of satisfaction defined by West-brook.20 In addition, an overall satisfaction rating question isincluded and intended to measure the overall satisfactionwith the services provided by all staff. The facets and corre-sponding survey questions are described in Table 2. A six-point Likert scale was used to collect responses, with possibleresponses varying depending on the question using either: 1. unsure; 2. not enough information; 3. almost enough infor-mation; 4. enough information; 5. a bit too much information;6. far too much information – in relation to information re-ceived, and: 1. unsure; 2. not at all; 3. a little bit; 4. somewhat;5. quite a bit (or mostly); 6. completely – in relation to othersurvey questions. A final comments section allows patientsto expand upon on any aspect of the survey or related to theirexperience.

Use of the survey commenced at the Centre in 2004. It wasdelivered on a quota basis, with staff on each of the treatmentunits providing the survey to the first 10 patients to finishtreatment on that unit at the start of each month. This methodwas chosen for two reasons. Firstly, it provided a means to in-tegrate the process of data collection into the operations ofeach treatment unit. Essentially, this data collection methodhas become “institutionalized” and is now a routine processwithin the department. Secondly, it allowed for a randomsampling of patients from throughout the whole departmentover a long period. By selecting the first 10 patients on amonthly basis, it reduced the potential for bias related to staffselecting favourable patients to complete the survey.

Patients had the option of returning the completed surveydirectly to staff, of completing the survey at home and return-ing it by mail or of depositing the survey in a confidential boxin the department. All surveys were anonymous and respon-dents were provided with information relating to the purposeof the survey. Patients were excluded if they were unable tounderstand written English, unable to complete the survey iftoo ill, or were pediatric patients. Survey results were enteredinto a Microsoft access database developed specifically forthe purpose.

There is a process for reporting the results of the survey tothe staff that can ultimately influence satisfaction. Resultsand comments are collated and shared quarterly amongstteam members. This provides team members an opportunityto identify areas where improvements can be made and alsoa mechanism for staff and the organization to receive feed-back from patients about the services provided to them. Sev-eral improvement initiatives were undertaken based on thefeedback. Most related to improving the educational materialsprovided patients, including developing materials in videoformats. Waiting rooms were improved and efforts made toreduce waiting times, specifically by adding new treatmentunits and by changing processes related to treatment plan-ning.

Data analysisTo investigate whether complete satisfaction with an as-

pect of care influenced overall satisfaction with services pro-vided by the RT team, logistic regression analysis was carriedout. The primary outcome of interest was the proportion ofpatients who were completely satisfied.For questions relatedto information received, a response of “enough” assumedcomplete satisfaction; all other responses assumed patientswere not completely satisfied with the information provided.All 15 measurements of satisfaction (categorized as com-pletely satisfied versus not completely satisfied) were consid-ered in the analysis along with time and the interaction oftime with each of the measurements. The influence of eachitem along with time and their interaction was first investi-gated individually to obtain information on whether the rela-tionship between complete satisfaction of each item andcomplete satisfaction overall changed over time. This was notthe case; therefore changes over time were no longer requiredand a forward selection method was then used to determinethe final satisfaction measurements and demographics thatinfluence patients’ overall complete satisfaction. Due to theintroduction of two new units at the end of 2006, differencesin patient satisfaction between treatment units used 2007 and2008 data only. Contingency table analysis using the Pearsonchi-square test was used as was a 5% significance level for allanalyses. Unknown responses to a question were excludedfrom analysis if the question was involved in the analysis. Allanalyses were carried out in SAS Version 9.1.3.

French and McGahan

TABLE 3Demographics results

Gender Percent Response Age Percent Response Education Percent Response

Female 55.4 <=30 1.9 Below Grade 12 15.5Male 42.8 31-40 5.1 Grade 12 23.7Unknown 1.8 41-50 15.1 Post-secondary 18.2

51-60 24.4 College/University 41.161-70 23.8 Unknown 1.571+ 29.3

Unknown 0.4



% R

espo

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Figure 1. Satisfaction with the amount of information given to patients.

Unsure Not enough Almost enough Enough Bit too much Far too much

Response item

% R

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Figure 2. Patients’ ability to understand the information given to them.

Unsure Not at all A little bit Somewhat Quite a bit Completely

Response item


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Figure 3. Satisfaction with the amount of information given to patients, 2004-2008.

Time

% c

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Figure 4. Patients’ ability to understand information given to them, 2004-2008

Quarter



% R

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Figure 5. Patient satisfaction with interactions with staff.

Unsure Not at all A little bit Somewhat Quite a bit CompletelyResponse

%

Figure 6. Patient satisfaction with interactions with staff, 2004-2008.

Quarter

% R

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Results and discussionA total of 3,188 surveys were completed between 2004 and

2008. Patient demographics in relation to gender, age groupand education level are shown in Table 3.

Four survey items measured satisfaction with the amountof information provided. For these items, 80.9% and 84.3% ofrespondents stated that they received “enough” informationabout the nature and extent of their illness, the RT treatmentthey had and the side effects of the treatment. However, upto 10% of respondents reported getting “almost enough” andjust over 3% “not enough” information (see Figure 1). Of thisinformation, at best, just under 50% reported that they “com-pletely” understood it with 40% reporting they understood it“quite a bit” and between 12.5 and 14% understanding it“somewhat” (see Figure 2). However, when measured overtime, the levels of satisfaction related to the amount of infor-mation and the ability to understand it did not show a trendtoward improvement (see Figures 3 and 4). These results sug-gest that while many patients receive sufficient information,few get too much and even more report not receiving enough.Similarly, a significant number of patients do not fully under-stand the information provided to them. However, efforts toincrease the amount of information provided to patients, forexample, providing information in different formats and re-vising written information, does appear to have led to an in-crease in satisfaction over time. These findings are consistentwith the results from the previous study using this surveytool,14 a fact that emphasizes the importance of providing pa-tients adequate and clear information.

Four survey items measured satisfaction with interactionswith staff. Ninety-one percent of respondents reported beingtreated with courtesy and respect, but only 67% were com-pletely satisfied with the help given about support services,58% with the help given with side effects and 48% with the ex-tent to which their questions and concerns were addressed(see Figure 5). Satisfaction with these areas also increasedover time (see Figure 6). It is notable that, overall, patientsreported being treated with courtesy and respect; however,the lower satisfaction ratings related to more practical helpfrom staff indicates that this area should be of concern andsubject to improvement.

Five survey items related to wait times. Overall, 73% of re-spondents were completely satisfied with the waiting areas(see Figure 7). However, this number varied over time, de-creasing from 2004 to 2006 before increasing again (see Figure8). This corresponds to periods when there were renovationsand disruptions to patient areas in the department, with anincrease in satisfaction levels once improvements to waitingareas were completed.

Complete satisfaction with wait times was lowest for thetime it took to see the doctor (50%) while satisfaction with thewait time for planning appointments and for treatment ap-pointments was 58% and 63%, respectively. Complete satis-faction with the appointment times assigned to patients was61%. Satisfaction with waiting times did increase over timeand corresponded with a general decrease in actual waitingtimes over the study period. This reinforces the importanceof waiting times to patients. The low satisfaction for appoint-

French and McGahan

% R

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Figure 7. Patient satisfaction with wait times and waiting areas.

Unsure Not at all A little bit Somewhat Quite a bit Completely



% R

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Figure 8. Patient satisfaction with wait times and waiting areas, 2004-2008.

Quarter

% R

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Figure 9. Overall satisfaction rating from 2004-2008.

Quarter


ments with physicians may be due to longer waits for theseappointments and the relative importance of this issue to pa-tients. More research in this area might be of use.

A single survey item measured overall satisfaction. Almost15% of respondents were mostly satisfied and 82% completelysatisfied with the services provided by the radiation therapyteam, and overall satisfaction increased over the time of thestudy. However, it should be noted that the relatively high lev-els of satisfaction reported on this item do not necessarilymatch the somewhat lower levels for some of the other items– indicating perhaps that a single item rating may not be to-tally sufficient to measure all facets of satisfaction.

To establish whether there were any determinants of sat-isfaction, we compared survey items to the overall satisfactionquestion. Several survey items were significantly related tothis rating (see Tables 4 and 5). The strongest relationship waswith whether patients felt they were treated with courtesy andrespect by staff (Odds Ratio (OR) of 5.0, p = <.0001). We sug-gest that this finding underlines the importance of the rela-tionship between patient satisfaction and how staff interactwith patients.

Demographically, satisfaction was highest in patients over50 (p = 0.0004); level of education also had an impact – thosereporting an education level of below Grade 12 had higheroverall satisfaction (p < 0.0001). It is not known whether per-sonal levels of satisfaction increase as patients age or whetherthis is a function of the differences between generations, inthat the younger “baby boomer” demographic is generally lesssatisfied and will remain so as they age.

An interesting finding was that gender did not have an in-fluence. Our results suggest that age and education levels aremore relevant to overall patient satisfaction. Items relating tounderstanding information and the information providedabout side effects also had no impact on the overall rating.

Satisfaction rates varied by treatment unit, with the lowestrates recorded on Unit 8, the unit where patients were treatedwith mostly palliative intent and normally with short fraction-ation courses (see Figure 10). This perhaps indicates a gap inrelation to the services provided to this patient populationand is worrisome given that this group has advanced ormetastatic disease and, consequently, higher needs comparedto other patient groups. Further work in strengthening the in-formation and support provided to these patients is war-ranted.

ConclusionOur study demonstrates that it is possible to collect and

analyze patient satisfaction over time, an important prereq-uisite for quality improvement initiatives. The methodologyused provides both a mechanism for providing feedback tostaff and for evaluating the impact of any subsequentchanges. The increase in satisfaction levels over time indi-cates that there has been some success resulting from variousinitiatives. However, overall data did identify areas where sat-isfaction levels could be further improved. These include pro-viding information and support to patients, particularly thosetreated with palliative intent, and reducing the wait times forvarious appointments. Further initiatives are ongoing in this

French and McGahan

% c

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Figure 10. Overall satisfaction with services provided by the RT team by treatment unit.


regard. The methodology used and the findings would betransferable to other radiation therapy departments and po-tentially to other health care environments and, in fact, thesurvey tool is now used at other centres within B.C.

AcknowledgmentsThe authors would like to thank all of the patients who

completed the survey and all radiation therapy program staffwho provide dedicated and excellent patient care. In particu-lar, we would like to thank Wendy Riva for her excellent dataentry skills.

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TABLE 4Odds of a patient being completely satisfied with overall services provided by the RT team, depending on their response to other items

Item

Treated with Respect by Staff (Q13)

Satisfied with Wait Area (Q18)

Concerns Addressed by Staff (Q11)

Patient Education

Satisfaction with Wait Time for Doctor Appointments (Q17)

Satisfied with Help Given to Manage Side Effects (Q10)

Patient Age Group

Satisfied with Wait Time for Treatment Appointments (Q16)

Satisfied with Information for Support Services (Q12)

Satisfied with Amount of Information on RT Treatment (Q6)

Satisfied with Information on Nature and Extent of Illness (Q4)

Satisfied with Times for RT Appointments (Q14)

Response

Completely vs. Not Completely



Below Grade 12 vs. College/UniversityGrade 12 vs. College/UniversityPost Secondary vs. College/University



51-60 vs. ≤ 5061-70 vs. ≤ 5071+ vs. ≤ 50



Enough vs. Too Much/Too Little



P-value

< .0001

< .0001

< .0001

< .0001

< .0001

< .0001

0.0004

0.0015

0.0015

0.0025

0.0062

0.0129

Odds Ratio

4.966

2.682

2.216

2.2711.8310.948

2.125

1.942

1.8511.6651.982

1.636

1.654

1.706

1.557

1.434

3.311

2.028

1.632

1.4841.2920.672

1.531

1.415

1.3041.1531.374

1.208

1.213

1.206

1.134

1.079

7.448

3.547

3.010

3.4752.5941.338

2.949

2.665

2.6252.4052.859

2.215

2.254

2.412

2.137

1.905

95% Confidence Interval

Odds Ratio of a Patient Being CompletelySatisfied with Overall Service

TABLE 5Factors that did not significantly influence overall satisfaction

Item Response P-value

Able to understand information on Side Effects (Q9) Completely vs. Not Completely 0.1143Gender Female vs. Male 0.1458Able to understand information on RT Treatment (Q7) Completely vs. Not Completely 0.1972Satisfaction with wait times for Treatment Planning Appointments (Q15) Completely vs. Not Completely 0.2376Able to understand information on Nature and Extent of Illness (Q5) Completely vs. Not Completely 0.4222Satisfied with information on Side Effects (Q8) Enough vs. Too Much/Too Little 0.8911


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findings. Australian Health Review 1993;16(1):75-88.

French and McGahan

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Measuring patient satisfaction with radiation therapy service delivery

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