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Hearing the Patient's Voice? Factors Affecting the Use of Patient Survey Data in Quality Improvement

In the Literature

As health systems in the United States and abroad strive to adopt the principles and practices of patient-centered care, they have begun to survey patients about their perceptions of care experiences. Hospitals, medical practices, and large government organizations like the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and the United Kingdom's National Health Service are all asking patients to provide feedback. But despite the stepped-up collection of information, experts know little about why variations in patient care persist and how survey data can actually be used in quality improvement.

For their Commonwealth Fund–supported study, "Hearing the Patient's Voice? Factors Affecting the Use of Patient Survey Data in Quality Improvement" (Quality & Safety in Health Care, Dec. 2005), Elizabeth Davies, Ph.D., a former Harkness Fellow based at King's College London School of Medicine, and Paul D. Cleary, Ph.D., of Harvard Medical School, sought to create a framework for understanding the factors that affect the use of patient survey data in quality improvement efforts. The researchers interviewed 14 senior health professionals and managers taking part in a quality improvement collaborative organized by the Institute for Clinical Systems Improvement in Minnesota, asking them to identify difficulties or successes they had experienced using patient feedback or survey data.

While the respondents described more barriers than successes, they also tapped into the potential secrets of success: focusing on system changes, rather than assigning individual blame, and developing cultures that support patient-centered care by emphasizing physician leadership, technical expertise, and organizational capacity.

Organizational Barriers
Organizational barriers reported by the participants ran the gamut—from the obstacles created by a traditional hierarchical management structure, to a lack of quality improvement infrastructure, to the issue of competing priorities like financial goals. Said one respondent, "The reimbursement for spending time with people is dramatically less than that given for procedures. This results in a feeling that we don't get paid for listening or supporting people."

Professional Barriers
From a professional perspective, using survey data presents a challenge to more traditional ways of working and thinking about care, respondents said. Many reported skeptical or defensive attitudes by staff to survey results. One participant said he needed a "bullet-proof vest" while presenting data, while others described the difficulty of changing doctors' independent behaviors. To help change such attitudes, respondents said it was important to engage senior clinical "enthusiasts" to bring along the masses.

Another professional challenge involved the personalities and communication skills of both administrative and clinical staff members. "A lot of it has to do with...their attitude toward giving information and making sure they explain things. And those are habits and personality issues," said one participant. One respondent reported that her practice had approached this issue by pairing low- and high-performing physicians for mentoring and further training.

Data-Related Barriers
The respondents also reported data-related barriers. Limitations included a lack of special expertise in working with survey data and the long delays from data collection to analysis and feedback. Further time delays—from feedback to intervention to additional measurement—could also make it difficult to determine whether interventions were actually effective or if improvements had been caused by other intervening factors. Participants also reported that data were often too general, making them difficult to interpret and translate into action. Said one respondent, "We didn't really have much success with being able to put our hands around anything and really improve anything based on the information that we were getting." Finally, some interviewees said that the high costs of data collection were also an impediment.

Findings from patient surveys, say the researchers, may prove surprising or uncomfortable to busy health care professionals who were previously unaware of any problems. It is important, they say, to neither dismiss patients' concerns nor blame individual clinicians. While results suggest that health care organizations must develop cultures that support quality improvement and patient-centered care, they also emphasize that the surveys themselves do not indicate what specifically needs to be done to improve the situation. Further commitment and ingenuity will be needed from health care professionals as well as policymakers, say the researchers, to understand shortcomings and develop solutions.

Framework for Factors Affecting the Use of Patient Survey Data to Develop Patient-Centered Care


  • Competing priorities
  • Lack of supporting values for patient-centered care
  • Lack of quality improvement infrastructure
  • Developing a culture of patient-centeredness
  • Developing quality improvement structures and skills
  • Persistence of quality improvement staff over many years

  • Clinical skepticism
  • Defensiveness and resistance to change
  • Lack of staff selection, training, and support
  • Clinical leadership
  • Selection of staff for their "people skills"
  • Structured feeback of results to teams or individuals

  • Felt lack of expertise with survey methods
  • Lack of timely feedback of results
  • Lack of specificity and discrimination
  • Uncertainty over effective interventions or rate of change
  • Lack of cost-effectiveness

Source: E. Davies and P.D. Cleary, "Hearing the Patient's Voice? Factors Affecting the Use of Patient Survey Data in Quality Improvement," Quality & Safety in Health Care, Dec. 2005 14(6):428-32.

Publication Details



E. Davies and P. D. Cleary, Hearing the Patient's Voice?, Factors Affecting the Use of Patient Survey Data in Quality Improvement, Quality & Safety in Health Care, December 2005 14(6):428–32