Despite a large literature describing and comparing patients' experiences of medical care, little is known about how such feedback can be used to improve patient-centered care [1
]. Studies in Europe, Australia and the United States (US) have suggested that collecting and reporting patient survey data may lead to small improvements in experience across health systems [5
] or within organizations [3
], but others have identified a range of difficulties confronting organizations and health professionals when they try to understand and respond to survey data, implement interventions, and sustain change [2
]. One US evaluation of a patient-centered care collaborative including eight health care organizations suggested that change was likely to require organizational strategies, engaged leadership, cultural change, and regular measurement and performance feedback [3
]. An interview study of staff responding to data the UK National Health Service (NHS) Patient Survey Programme found these data were generally perceived positively, had potential as performance measures and to be used to develop patient-centered cultures [12
]. A detailed review of four years of patient surveys in eight Danish hospitals suggested that staff viewed data positively when they perceived them as revealing problems that led to change and improvement [13
]. A review by Shaller of patient-centered practices in leading US organizations identified likely change strategies as the development and training of leaders, internal rewards and incentives, training in quality improvement, and practical evidence-based tools for patient-centered care [14
]. In the United Kingdom, Goodrich & Cornwell recently noted that although there are promising interventions, few have been independently evaluated [15
Since the 1990's, the US Veterans Health Administration (VA) has made a large investment in the collection and feedback of data on clinical processes, outcomes, and patients' experiences as part of a program of transformational re-engineering and performance improvement [16
]. This has resulted in improvements in immunization rates, cancer screening, and other prevention activities, as well in as the management of cardiovascular disease and diabetes [17
]. Although few reports consider patient experience in detail, Young reported a 15% improvement between the years 1995 and 1999 [19
], and the overall satisfaction of VA patients with hospital care was higher than for patients in the private sector in 2004 and 2006 [16
]. Thus, we thought that VA staff would be a rich source of information regarding the effective use of survey data. Previous studies suggested to us that a combination of organizational focus and support and sustained motivation and understanding of data by staff was necessary to create change in survey results [2
]. It also seemed likely that such complex change would take several change cycles over several years to achieve. Therefore, we conducted case studies of two VA facilities; one which had stable high scores and one with stable low scores. The specific goals and corresponding hypotheses for the study were:
1) To determine the promoters and barriers that health professionals and managers experienced when using patient survey results. Here we hypothesized that there would be support for survey data use within the VA, that teams would have needed to do much extra work to understand their data and "diagnose" the cause of poor patient experience results before acting; and that they would be driven to do this by long-term intrinsic motivation rather than by short-term external incentives.
2) To determine what types of supportive improvement strategies are necessary for implementing and sustaining patient-centered care. We hypothesized that these would be multi-stage and iterative, having effects over several years.
3) To assess whether improvements were related to support for developing patient-centered care, quality improvement structures, project management, and specific interventions. We hypothesized that improving and high performing facilities would demonstrate prior development of an organizational culture that promoted patient-centered care, including a coherent and data-driven overall quality improvement strategy supported by clinical leadership.