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Measuring patient experiences in primary health care : a review and classification of items and scales… Wong, Sabrina T.; Haggerty, Jeannie May 31, 2013

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Measuring Patient Experiences  in Primary Health CareA review and classification of items and scales used  in publicly-available questionnairesMay 2013Sabrina T. Wong, RN, PhDUniversity of British ColumbiaJeannie Haggerty, PhDMcGill UniversityMeasuring Patient Experiences in Primary Health Care: A review and classification  of items and scales used in publicly-available questionnaires was produced by:Centre for Health Services and Policy ResearchUniversity of British Columbia201–2206 East MallVancouver, BC V6T 1Z3Phone: 604-822-4969Email: enquire@chspr.ubc.caYou can download this publication from www.chspr.ubc.caLibrary and Archives Canada Cataloguing in PublicationWong, Sabrina T., author          Measuring patient experiences in primary health care: a review and classification of items and scales used in publicly-available questionnaries / Sabrina T. Wong, RN, PhD, Universityof British Columbia, Jeannie Haggerty, PhD, McGill University.“May 2013.”Electronic monograph in PDF format.ISBN 978-1-897085-22-6 (pdf)           1. Patient satisfaction--Canada--Measurement.  2. Patientsatisfaction--Canada--Evaluation.  3. Medical care surveys--Canada--Evaluation.  4. Primary health care--Canada--Evaluation.5. Medical care surveys--Canada--Evaluation.  I. Haggerty,Jeannie, author  II. University of British Columbia.  Centre forHealth Services and Policy Research  III. Title.RA399.C3W65 2013                    362.1072’3                C2013-903466-81Contents2	 About	CHSPR2	 About	the	Canadian	Primary	Health	Care	Research	and	Innovation	Network3	 Forward4	 Executive	Summary5	 1.	Introduction5	 1.1.	Contribution	of	Patient	Experiences	in	Primary	Health	Care	(PHC)	to	the			 							Performance	of	Health	Care	Systems5	 1.2.	Developing	a	Tool	to	Measure	Patient	Experiences	in	PHC	6	 1.3.	This	Report	7	 2.	Objectives	of	the	Review8	 3.	Methodology8	 3.1.	Defining	Dimensions	of	Patient	Experiences	in	PHC10	 3.2.	Identifying	Relevant	Instruments	and	Surveys10	 3.3.	Classification11	 4.	Results11	 4.1.	Dimensions	of	Patient	Experiences	in	Primary	Health	Care	Covered	by	Existing		 		 							Surveys	and	Instruments14	 5.	Discussion14	 5.1.	Instruments	and	Surveys	Selected14	 5.2.	The	Patient	Experiences	Survey	15	 5.3.	Limitations	and	Strengths16	 6.	Conclusion17	 7.	References23	 8.	Appendix23	 8.1.	Classification	of	the	Items	from	the	Selected	Survey	Tools23	 8.2.	Access24	 8.3.	Interpersonal	Communication	26	 8.4.	Continuity	and	Coordination28	 8.5.	Comprehensiveness	of	Services29	 8.6.	Patient	Reported	Impacts	of	Primary	Health	Care30	 8.7.	Trust31	 9.	AcknowledgementsUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r ChM e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e2About CHSPRAbout the Canadian Primary Health Care Research and Innovation Network (CPHCRIN)The Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to advance scientific enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda. The Centre’s work is:• Independent• Population-based• Policy relevant• Interdisciplinary• Privacy sensitiveCHSPR aims to contribute to the improvement of population health by ensuring our research is relevant to contemporary health policy concerns and by working closely with decision makers to actively translate research findings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-gov-ernment organizations in British Columbia (BC), Canada and abroad. For more information about CHSPR, please visit www.chspr.ubc.ca.Established in October 2011, CPHCRIN is a research, training, and knowledge exchange network whose vision and operations are informed by an understanding of the contribution to performance and capacity building that can be made by a pan-Canadian research network, and by an inclusive approach. The network acts as a rich heterogeneous forum that yields creative discussion and debate about the future of CBPHC in Canada, and that allows us to better address the pressing challenges of today with a research agenda that encompasses a vast number of questions, perspec-tives, and methodologies. CPHCRIN facilitates the creation, translation, and scale-up of innovative models of CBPHC, in order to influence the efficiency and effectiveness of health care in Canada. For more information about CPHCRIN please visit www.cphcrin-rcrissp.ca.ForwardThe Canadian Primary Health Care Research and Innovation Network (CPHCRIN) is pleased to host three important and related scoping reports on measurement in primary health care (PHC). Measurement is basic to organizational quality improvement, reporting, and accountability and research to improve our understanding of primary health care (PHC) service delivery. Stakehold-ers, including decision-makers, clinicians, and researchers, very often need to collect data that is best reported by practices, clinicians, and/or patients to answer  practice and research questions.There are three separate but related technical reports that are companions to the Canadian Insti-tute for Health Information (CIHI) suite of PHC organizational, provider, and patient experience surveys. The authors of these three reports scanned international scientific and grey literature to bring together the many varied ways different people have tried to measure the delivery and expe-rience of primary care service. The organizational and provider reports bring together, for  the first time, information on different dimensions of PHC best reported on by organizations or  clinicians. The patient report updates and builds on work that examined patient experiences in PHC. All authors have reviewed and classified measurement items and scales used in publicly-available questionnaires. CIHI also sought feedback from stakeholders on the development of  the suite of surveys.This work is the first step in preparing a suite of new PHC surveys that captures dimensions of PHC important to Canadians. The hope is that these surveys will be widely adopted and used. Standardized surveys bring the advantage of allowing comparisons with work done by other juris-dictions in other contexts. CPHCRIN encourages researchers and other stakeholder groups to use, where ever possible, the resulting new suite of surveys. Should it happen that your particular area of enquiry is not fully addressed in the new surveys, these reports will provide you with a compre-hensive list of tools or indicators which might better address your particular need. It is expected that these scoping reports will save you time as they present the many different ways questions have been asked to try to understand PHC service delivery.   CIHI provided financial and staffing support for this work.  The final suite of three new surveys is available on the CIHI website at  www.cihi.ca/phc.Sincerely, Dr. William Hoggon behalf of the CPHCRIN Executive CommitteeUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e4Executive SummaryMonitoring information about patients’ experiences is essential to stimulate innovation, track changes in quality, and help Canadians become more informed about their health care system. Measuring the quality of the primary health care (PHC) system from patients’ perspectives has been identified as a crucial step towards defining areas of improvement and monitoring the impact of change. Regularly scheduled PHC surveys have been recommended as a future data collection strategy. However, no standardized, self-reported or comparable PHC survey currently exists for use with patients across Canada.The purpose of this review was to identify items and scales to inform the composition of a core Patient Experience Survey for use across Canada. This scoping review provides an up-to-date review of the publicly available instruments that purport to measure patients’ experiences in PHC.The three main objectives of this review were to:1. Identify the relevant instruments and surveys assessing patients’ experiences in PHC; 2. Classify items and questions in the appropriate dimensions of patient experiences; and 3. Provide a foundation for the Patient Experience Survey instrument for the Canadian Institute for Health Information (CIHI) Primary Health Care Survey project.The Patient Experiences Survey was developed based on a review of relevant conceptual frameworks related to performance measurement of the PHC system, and past work that provides operational definitions of dimensions relevant to PHC from patients’ reports of their PHC experiences. Relevant instruments and surveys were assessed based on previous work, an environmental scan of health surveys completed by CIHI and a review of national and international the peer-reviewed and grey literature. Items for inclusion in the Patient Experience Survey were based on two criteria: 1) relevant to patients’ experiences in PHC and 2) publicly available. Instruments and surveys published in English and French were reviewed. A total of 17 instruments and surveys were retained. The instruments varied in size as did the number of dimensions and sub-dimensions. The Patient Experience Survey measures six dimensions (15 sub-dimensions) of PHC that are best measured based on patient reports: 1) Access, 2) Interpersonal Commu-nication, 3) Continuity and Coordination, 4) Health Promotion within Technical Quality of Care, 5) Trust, and 6) Patient-Reported Impacts of Care.This work highlighted that many surveys and instru-ments exist to assess patient experiences in PHC and that no instrument or survey offered full coverage of dimensions of PHC important to patients. The items used to develop the Patient Experience Survey are meant to capture various aspects of how the PHC system is performing. This Patient Experience Survey contains items that measure outputs and immediate outcomes of PHC that are best reported by patients. The immediate outcomes of PHC are considered patient-reported impacts of PHC delivery.The length of the survey administered to patients  will depend ultimately on the dimension and sub-dimension of interest and the purpose for which the survey is being conducted. Therefore, choosing dimensions and sub-dimensions of interest, rather than specific items, should be identified prior to survey administration.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch51.1. Contribution of Patient Experiences in Primary Health Care (PHC) to the Performance of Health Care SystemsHealth care systems with a strong foundation of primary health care (PHC) are recognized for improv-ing the overall health of populations.[1-3] To improve access to health care for Canadians, decision-makers have made a number of commitments supporting the reform towards the organization, financing and delivery of PHC.[4, 5] By focusing on access to services, continuity of care, effectiveness, safety, responsiveness and comprehensiveness[2, 3, 6] in PHC, it is expected that patients would report a great impact on  their health.Monitoring information about patients’ experiences is essential to stimulate innovation, track changes in quality, and help Canadians become more informed about their health care system.[7] A well-constructed PHC survey offers a window into patients’ perceptions that is otherwise unavailable.[8] Patients are uniquely positioned to report on their care experiences and they are often the only common thread across dispa-rate health care settings.[9] Consequently, measuring the quality of the PHC system from patients’ perspec-tives has been identified as a crucial step towards defining areas of improvement and monitoring the impact of change.[10] Regularly scheduled PHC surveys have been recommended as a future data collection strategy.[11] However, no standardized, self-reported or comparable PHC survey currently exists for use with patients in Canada.1.2. Developing a Tool to Measure Patient Experiences in PHC The Canadian Institute for Health Information (CIHI) led the development of a suite of three survey instru-ments for PHC organizations, providers and patients that can be used to measure performance of PHC. This scoping review was part of the Primary Health Care Survey project of the CIHI and was done in order to support the creation of the patient experience questionnaire that could be used to assess the quality and performance of PHC in Canada. The purpose of this review was to identify survey elements to inform the composition of a core patient experience survey instrument that could be used across Canada.In Canada, research in primary health care has not fully utilized patient reports of the their experiences. [12] Patients who have ever used PHC offer valuable contributions to the improvement of their care. They can be definers of good quality, evaluators of health care delivery and reporters of their experiences.[13] As participants in health care delivery, they can influ-ence the quality of care in more direct ways, such as involvement in decisions concerning medical treat-ment. Patients’ perspectives for assessing the quality of care focuses on aspects of service delivery important for patients.[14, 15] Ongoing monitoring of patients’ experiences using self-report surveys combined with routine feedback to PHC providers can lead to practice improvements and internal quality control; it also enhances a culture of patient engagement.[16] Engaging patients increases the likelihood that they can carry out agreed-upon treatment plans to the best of their abilities. Patients who are engaged in under-standing their condition are more likely to report a better quality of life and satisfaction with PHC.[17] Outcomes of ongoing monitoring and feedback include enhancing patient choice of provider, better adherence to medical advice,[18-20] and reduced rates of complaints,[21] grievances,[22] and the level and serious-ness of malpractice claims.[23, 24] It can affect functional health outcomes and actual health.[16, 19, 25, 26] 1. IntroductionM e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e6Some developed and validated self-report PHC instruments have been used in Canada, but no single instrument captures all dimensions of the quality of PHC important to patients. Two instruments used commonly to measure the quality of PHC in Canada are the Primary Care Assessment Tool (PCAT)[27] and the Primary Care Assessment Survey (PCAS).[28, 29] The PCAT[27] consists of five PHC domains: strength of affiliation with provider, first contact (accessibility and use), ongoing care (relational longitudinality), comprehensiveness (availability and provision of services), and coordination (medical record continu-ity and integration of care). The PCAS[28, 29] contains seven PHC domains: accessibility (financial and organizational), continuity (longitudinal and visit-based), comprehensiveness (contextual knowledge of the patient and preventive counseling), integration, clinical interaction (physician-patient communica-tion, thoroughness of examination), interpersonal treatment, and trust.[30-32] Both of these instruments are long and measure different dimensions of PHC. Other self-report generic PHC instruments such as the Components of Primary Care Index,[33] the EUROPEP,[34, 35] and the Ambulatory Care Experi-ences Survey (ACES)[8] have been shown to be valid for Canadians, and have been translated into French. None of these instruments have been validated for other languages commonly spoken in Canada such as Chinese or Punjabi. There are several distinctions between instruments, but the biggest issue is that the use of different instruments makes it very difficult to compare patient experiences over time or between regions. Development of a reliable and validated Canadian PHC instrument will provide a standard-ized measure that can be used to monitor the quality of the PHC system from the patient perspective. Since 2000, there has been considerable interest in collecting patients’ perspectives on health and health care. There are existing surveys collecting PHC infor-mation, including the Canadian Community Health Survey (CCHS),[36] the Health Services Access Survey (HSAS),[37] the Canadian Survey of Patient Experi-ences with Primary Health Care (CSE-PHC)[38] and the Commonwealth Fund International Health Policy Survey.[39] The CCHS is a population-based survey, administered by Statistics Canada using both computer-assisted personal and telephone interviews every two years, that collects a broad range of health information.[36] The HSAS is a supplement to the CCHS. The HSAS is conducted at irregular intervals, designed to collect information on patient experi-ences of access to first contact services and waiting time for key diagnostic and treatment services.[37] The CSE-PHC was conducted in 2007 with a nationally representative Canadian sample.[38] The Common-wealth Fund International Health Policy survey is a yearly survey conducted in Australia, Canada, New Zealand, the U.K., and the U.S.[39] It collects infor-mation on access, emergency care, coordination, continuity, and consumer-physician interactions, but these data are not publicly available for research or planning use. 1.3. This Report This scoping review provides an up-to-date, interna-tional review of the publicly available instruments that purport to measure patients’ experiences in PHC. We provide a classification grid of the different dimen-sions currently measured in these surveys and classify the items and instruments that measure different dimensions. The survey tools reported here help us to elaborate a more complete set of measures in order to allow users to capture many dimensions of patient experiences relevant to PHC.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch72. Objectives of the ReviewThis review aims to draw a global portrait of the main items and question formulations found in instru-ments that can be used to measure patient experiences relevant to PHC. The three main objectives of this scoping review were:1. To identify the relevant surveys and tools  assessing the patients’ experiences in PHC; 2. To classify any single items and questions in the appropriate dimensions of patient experiences. 3. To provide a foundation for the Patient Experi-ence Survey Instrument for the CIHI Primary Health Care Survey project.M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e83. MethodologyThe Patient Experiences Survey was developed based on a review of relevant conceptual frameworks related to performance measurement of the PHC system and past work that provides operational definitions of dimensions relevant to primary care[40] and patients’ reports of their experiences in PHC.[41, 42] We devel-oped a pool of relevant items that could be used to measure dimensions of PHC best reported by patients. Once the survey was constructed, we used cogni-tive or “think-aloud” interviews[43, 44] with English and French-speaking participants (n=15) living in Montreal in order to examine whether items were understood in the way we intended. All procedures for conducting the cognitive interviews were approved by St. Mary’s Hospital, Montreal, Quebec. 3.1. Defining Dimensions of Patient Experiences in PHCDimensions of patient experiences in PHC were iden-tified from three main sources. First, Haggerty et al.[40] proposed 25 different dimensions to consider when assessing the impacts of PHC renewal initiatives. The 25 dimensions are categorized into five groups: clini-cal practice attributes, practice structural dimensions, person-oriented dimensions, community-oriented dimensions, and system performance dimensions. There are dimensions found to be specific to primary care: accessibility-first contact, continuity-relational, family-centered care, intersectoral team, population orientation. Of the 25 dimensions defined by Hag-gerty et al., some dimensions relevant to PHC are best measured using patients’ reports of their experiences, notably accessibility, continuity, and interpersonal communication.[40, 42]Second, our work was informed by the Framework for Primary Care created by Hogg et al.[45] They devel-oped a conceptual framework designed to support the measurement of PHC system performance in two complementary domains: structural and performance. “The structural domain describes the health care system, practice context and organization of the prac-tice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care”.[45, p.398] Finally, our work was informed by the PHC Logic Model.[46] This model identifies inputs, outputs, and immediate, intermediate, and final outcomes. The PHC Logic Model outputs rely on the identification of important dimensions of PHC by Haggerty et al.[40] We specifically drew on the PHC Logic Model imme-diate outcomes in creating the Patient Experience Survey since increased knowledge about health and health care among the population and reduced risk and effects of continuing conditions “are, for the most part, under the direct control of the PHC sector.”[46, p.7] Based on our review of these main sources, six dimen-sions of PHC are important to measure from patients’ perspectives: 1. Access2. Interpersonal Communication 3. Continuity and Coordination 4. Health Promotion within Technical Quality  of Care 5. Trust6. Patient-Reported Impacts of Care. Each dimension (see Table 1) includes a brief defini-tion. In total, our classification yielded six dimensions and 15 sub-dimensions of patient experiences in PHC.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9Table	1:	Dimensions	of	patients’	experiences	in	primary	health	careDimension Sub-dimension Definition AccessFirst	contact		accessibilityThe	ability	to	obtain	patient-or	client-initiated	needed	care	(including	advice	and	support)	from	the	provider	of	choice	within	a	time	frame	appropriate	to	the	urgency	of	the	problem.[40]AccomodationThe	relationship	between	how	resources	are	organized	to	accept	patients	or	clients	(including	appointment	systems,	hours	of	operation,	walk-in	facilities,	telephone	services)	and	the	patients’	or	clients’	ability	to	accommodate	to	these	factors	to	realize	access.[40]Economic		accessibilityThe	extent	to	which	direct	or	indirect	costs	related	to	care	impeded	decisions	to	access	needed	care	or	continue	recommended	care.	Interpersonal communica-tionGeneral		communicationThe	ability	of	the	provider	to	elicit	and	understand	patient	or	client	concerns,	and	to	explain	health	and	health	care	issues.[40,	47]RespectfulnessThe	ability	of	the	primary	care	organization	and	practitioners	to	provide	care	that	meets	the	expectations	of	users	about	how	people	should	be	treated,	such	as	regard	for	dignity	and	provision	of	adequate	privacy.[40,	47]	Shared		decision-makingThe	extent	to	which	patients	or	clients	are	involved	in	making	decisions	about	their	treat-ment.[47]Whole-person		careThe	extent	to	which	providers	address	the	physical,	emotional	and	social	aspects	of	a	patient’s	or	client’s	health	and	consider	the	community	context	in	their	care.[40]Continuity and coordinationRelational		continuityA	therapeutic	relationship	between	a	patient	or	client	and	one	or	more	identified	providers	that	spans	separate	health	care	episodes	and	delivers	care	that	is	consistent	with	the	patient’s	or	client’s	biopsychosocial	needs.[40]Information		continuityThe	extent	to	which	information	is	used	to	make	current	care	appropriate	to	the	patient	or	client.	CoordinationThe	provision	and	organization	of	a	combination	of	health	services	and	information	with	which	to	meet	a	patient’s	or	client’s	health	needs,	including	services	available	from	other	community	health	service	providers.[9,	10]Team	functioningThe	ability	of	primary	health	care	providers	to	work	effectively	as	a	collaborative	team	to	manage	and	deliver	quality	patient	or	client	care.	Comprehen-siveness of servicesServices	providedThe	provision,	either	directly	or	indirectly,	of	a	full	range	of	services	to	meet	patients’	or	clients’	health	care	needs.	This	includes	health	promotion,	prevention,	diagnosis	and	treat-ment	of	common	conditions,	referral	to	other	clinicians,	management	of	chronic	condi-tions,	rehabilitation,	palliative	care	and,	in	some	models,	social	services.[40]	Health		promotion	and	primary	preventionHealth	promotion	is	the	process	of	enabling	people	to	increase	control	over,	and	to	improve,	their	health.[12]	Primary	prevention	is	directed	towards	preventing	the	initial	occur-rence	of	a	disorder.[13]	TrustAn	expectation	that	the	other	person	will	behave	in	a	way	that	is	beneficial	and	that	allows	for	risks	to	be	taken	based	on	this	expectation.	For	example,	patient	or	client	trust	in	the	physician	provides	a	basis	for	taking	the	risk	of	sharing	personal	information.[48]Patient-reported impacts of carePatient	activationPatient’s	or	client’s	ability	or	readiness	to	engage	in	health	behaviors	that	will	maintain	or	improve	their	health	status.[49,	50]Patient	safetyPatient’s	or	client’s	reports	of	medication	errors	(given	or	taken	the	wrong	drug	or	dose)	or	incorrect	medical	or	laboratory	reports	and	communication	with	their	provider	about	not	taking	their	prescribed	medication	or	medication	side	effects.Confidence	in		the	PHC	systemThe	perception	that	allows	patients	or	clients	of	health	care	to	make	decisions	since	they	assume	(and	expect)	relative	certainty	about	providers	delivering	safe	and	technically	competent	care.[51]M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e1 03.2. Identifying Relevant Instruments and SurveysRelevant instruments and surveys were assessed based on previous work completed by Wong[52, 53] and Haggerty,[54] an environmental scan of health surveys completed by the CIHI, and a review of the peer-reviewed and grey literature. The literature review focused on material (published and unpublished) available in Canada related to the identification of  different dimensions of patient experiences in PHC,  as well as on international material (specifically, from Europe, Australia, New Zealand and the United States) that had the potential to be applied in a Cana-dian setting.The items identified from the instruments and surveys for inclusion in the Patient Experience Survey were selected based on two criteria: 1. Relevant to patients’ experiences in PHC 2. Publicly available. Instruments and surveys published in English and French were considered for review. 3.3. ClassificationInformation available from instruments and surveys was entered into a Microsoft Excel data table. For each instrument and survey, a research assistant classified the items within the dimensions of patient experi-ences in PHC (see Table 1). Once the items were classified, two independent observers (Haggerty & Wong) assessed the relevance of the classification. Tables were then iteratively adjusted until the authors reached consensus with regards to which item should be attributed to each dimension. The instrument or survey covered at least one item in a dimension in order to obtain a check mark; that is, the number of items from the same instrument or survey within a dimension was not a factor for inclu-sion in this table. UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 14. ResultsIn reviewing the literature, we found many instru-ments and surveys that assessed patient experiences in PHC. As part of the work for this report, we also reviewed the New Brunswick Patient Health Care Experience Survey,[55] the Manitoba Physician Integrated Network patient survey,[56] The Ontario Primary Care Access Survey,[57] and the Nova Scotia Primary Care Practice Survey.[58] No items from these surveys were retained since they were mainly based on previously identified instruments (e.g., Primary Care Assessment Tool[59]). Additionally, several other instruments and surveys were reviewed and informed the final Patient Experience Survey; these included work completed in a number of different countries. Instruments and surveys from Europe included EUROPEP[60] and Quality and Cost of Primary Care (QUALICO-PC) Patient Exeriences and Patient Values questionnaires.[61] Instruments and surveys from the United States included Compo-nents of Primary Care Index,[33] Patient Satisfaction Questionnaire Short Form (PSQ-18),[62], VA National Outpatient Customer Satisfaction Survey,[63] The Con-sultation Quality Index[64], Measure of Processes of Care[65], Patient Experiences Questionnaire[66], Patient Perception of Patient Centred Care,[67] Patient Activa-tion Measure Short Form[49], and Patient Enablement Index.[68] We retained a total of 17 instruments and surveys from which items were retained for the final Patient Experience Survey (see Table 2). The instruments varied in size (long or short version) as did the number of dimensions and sub-dimensions (e.g., accessibility, continuity, interpersonal processes of care). Most of them aimed to measure access and con-tinuity of care experiences. The processes of care such as respectfulness of the provider, shared decision-making, and coordination of care were also widely measured by these instruments.The instruments and surveys varied in length (from 12 questions to more than 250 questions). They also varied as to whether the patient was asked to respond about their most recent visit or about their general experiences in PHC with their usual provider over the last 12 months.The 17 instruments and surveys were designed to be used mostly in primary care settings; ten were created in a country other than Canada, one was an interna-tional initiative (Commonwealth Fund International Health Policy survey) and nine were administered only in Canada. The geographic areas covered by each survey tool varied from one study to another: international (e.g., QUALICO-PC=34 countries, Commonwealth Fund=10 countries), national (e.g., Canadian Survey of Experiences with PHC, General Practice Assessment Questionnaire) and regional (e.g., Accessibilité Rurale II, Interpersonal Processes of Care). All surveys and the majority of studies using these instruments are cross-sectional, collecting data at one point in time.4.1. Dimensions of Patient Experiences in Primary Health Care Covered by Existing Surveys and InstrumentsTable 3 shows the coverage of patient experiences in PHC dimensions by the surveys and instruments. No one survey or instrument covered the entire range of patient experience in PHC dimensions.M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e1 2Origin Name of the survey / project Acronym# Items retained for pt. experi-ence survey***CanadaCanadian	Survey	of	Experiences	with	Primary	Health	Care,	2007[69] CSE-PHC	2007 3Canadian	Community	Health	Survey[36] CCHS 11Québec (Canada)Accessibilité	Rurale	II	[70] 6RuralII[71]Questionnaire	populationnelle[72]	 QPop 1Management	Continuity[73] 17British Columbia (Canada)*Patient	Experiences	in	Primary	Care	in	BC[53]	/	Patient	Experiences	in	Primary	Care:	BC,	Manitoba,	and	Quebec[52]13United Kingdom**National	Health	Service	Patient	Survey[74] NHS	patient	survey 8General	Practice	Assessment	Survey[75] GPAS 4General	Practice	Assessment	Questionnaire[76] GPAQ 11United StatesConsumer	Assessment	of	Health	Plan	Survey	clinician	and	group	survey,	2011[77]CAHPS 1Interpersonal	Processes	of	Care	original	and	short	form[47,	78])	 IPC 17Primary	Care	Assessment	Tool[79] PCAT 3Primary	Care	Assessment	Survey,	Ambulatory	Care	Experiences	Survey[29,80] PCAS/ACES 4Patient	Assessment	of	Care	for	Chronic	Conditions[81] PACIC 4Commonwealth	Fund	International	Health	Policy	Survey[82] CWF 3Table	2:	Retained	surveys	and	instruments	from	which	the	patient	experience	survey	was	developedThree	questions	on	patient	activation	in	the	Patient	Experiences	surveys	were	informed	by	Hibbard	et	al’s[49]	work.	Several	annual	versions	of	the	NHS	patient	survey	were	reviewed.	Seven	items	on	the	CIHI	Patient	Experience	survey	showed	up	in	more	than	one	survey	(questions	3,	4,	5,	6,	18,	19,	and	20).	One	question	 in	the	Dimension	of	Patient	Reported	 Impacts	of	Care	was	created	during	this	process:	“In	the	 last	12	months,	have	you	taken	the	wrong	medication	or	wrong	dose	that	was	prescribed	to	you	by	a	doctor,	nurse,	or	pharmacist?	Responses:	Yes,	No,	not	that	I	know	of”******UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3	Table	3:	Summary	of	the	classification	of	the	survey	and	instruments	CSE-PHCAccessibilité Rurale II/IIIQPopManagement ContinuityPatient Experiences in PHC: BC/BC, Manitboa, QuebecNHS Patient SurveyGPASGPAQCAHPSIPCPCATPCAS/ACESPACICCWFAccessFirst	contact		accessibilityx x x x x x x x x x xAccomodation x x x x x x x x x x xEconomic	accessibility	 x x x x xInterpersonal communicationGeneral		communicationx x x x x x x x x x x xRespectfulness x x x x x x x xShared	decision-making x x x x x x xWhole-person	care x x x x x x x x x x x xContinuity and coordinationRelational	continuity x x x x x x x x x x xInformation	continuity x x x x x xCoordination x x x x x x x x xTeam	functioning x x x x x x x xComprehensiveness of servicesServices	provided x x x x x x xHealth	promotion	and	primary	preventionx x x x x x x x x xTrust x x x x x xPatient-reported impacts of PHCPatient	activation x x x x xPatient	safety x x x x xConfidence	in	the		PHC	systemx x xNote:	The	Canadian	Community	Health	Survey	(CCHS)	is	not	included	here	since	the	items	obtained	were	sociodemographic	questions	only.	M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e1 45. Discussion5.1. Instruments and Surveys SelectedMany instruments and surveys assessed patient expe-riences relevant to PHC. The majority of instruments and surveys were administered face-to-face or over the telephone. All instruments and surveys were avail-able in English, with fewer being available in English and French. As mentioned above, some instruments and surveys offered better coverage than others. The majority of instruments and surveys did not include known patient reported outcome measures such as functional and emotional health status.This work highlights the fact that many instruments and surveys exist to assess patient experiences in PHC. While most dimensions of PHC that are best reported by patients are covered by existing tools, certain dimensions about the quality of care remain under-developed. For example, the dimensions of: coordination, trust with provider and the practice, and team functioning could be further developed to more fully capture patients’ reports of these experiences. These dimensions are important aspects of patients’ care that can influence their health status and use of health services. No single instrument or survey will likely offer the full coverage of patient experience dimensions relevant to PHC. The review of instruments and surveys helps clarify the dimensions which are measured by each item that in turn will facilitate the selection of the questions depending on the research aim. This review could be useful to those intending to measure multiple dimensions of patient experiences in PHC. 5.2. The Patient Experiences Survey The instrument and survey items identified in this review informed the content of the Patient Experi-ences Survey. We attempted to cover all dimensions of care that can be accurately and precisely measured by patient reports and ratings. There are a total of six dimensions of care captured with the Patient Experi-ences Survey: Access, Interpersonal Communication, Continuity and Coordination, Comprehensiveness of Services, Trust, and Patient-Reported Impacts of PHC. These dimensions cover outputs and immediate outcomes of PHC that are best reported by patients. The immediate outcomes of PHC are considered patient-reported impacts of PHC delivery. The majority of dimensions include between two and four sub-dimensions. For example, within the dimen-sion of Interpersonal Communication there are four sub-dimensions: General Communication, Respect-fulness, Shared Decision-Making, and Whole-Person Care. Several items (n=20) are provided to measure these four sub-dimensions. The number of items used to measure the various dimensions and sub-dimen-sions of patient experiences may seem daunting. The length of the survey administered to patients will depend ultimately on the dimension and sub-dimen-sion of interest and the purpose for which the survey is being conducted. Therefore, choosing  dimensions and sub-dimensions of interest, rather than specific items, should be identified at the begin-ning of the survey process as the time needed to  complete the survey can impact costs and response rates. We suggest that these dimensions and sub-dimensions capture various aspects of how the PHC system is performing.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5For the various items, we often adapted questions and/or response options to ensure that the survey was coherent and that there was consistency in the reference or frame used. In various instances, we had conducted research that allowed us to determine more suitable response options.[83-86] The Patient Experi-ences Survey captures both patients’ reports of their experiences immediately following their visit and also their experiences in PHC over the past 12 months. Although cognitive interviewing has informed the construction of the Patient Experiences Survey, planned validation of the instrument will provide insight into items that measure common underlying constructs (which we expect to correspond to attri-butes of care) and whether there are places for item reduction with little impact on construct validity. 5.3. Limitations and StrengthsIn building our summary of the classification of items found in the instruments and surveys, we were limited in assessing the appropriate coverage of various dimensions/sub-dimensions as we resorted to a simple covered/not covered dichotomy. Further research would be necessary to analyze the depth in which each dimension is covered by each survey or instru-ment selected. Futher, an overall assessment of how well the instruments and surveys perform amongst various groups (e.g., men vs. women, older adults with multiple chronic conditions, those who are marginal-ized by multiple intersecting determinants of health) was not performed. Our intent was solely to map the surveys and instruments to a set of attributes seen as important in evaluating PHC performance from patients’ perspectives. Finally, we did not perform an in-depth analysis of the reliability or validity of the different instruments and surveys. The Patient Experi-ence Survey did undergo cognitive testing in English and French to assess whether the item was interpreted as intended by patients. Content validation of our survey was assessed by garnering feedback from the larger PHC research community.This work was aimed at identifying the relevant dimensions of PHC best measured through patient reports. However, we cannot be sure that we have captured all available and relevant surveys and instru-ments. While we are confident that our review of surveys and instruments captured the most used tools, it could be that there are dimensions of PHC best cap-tured through patient reports that were missed. One example is how the dimension of Equity, the extent to which access to health care and quality services are provided on the basis of health needs, without systematic differences on the basis of individual or social characteristics[40], is not measured by the Patient Experiences Survey. Work is currently underway by Browne, Varcoe, and Ford-Gilboe[87] to construct and pilot test questions that will capture the dimension of Equity from patients. M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e1 66. ConclusionTo support current measurement of patient experi-ences in PHC, it is important that health providers, managers, patients and decision-makers have access to a greater number of convincing and comparable data (existing and new). The number of dimensions of PHC best reported by patients, as we have seen in the work of Haggerty et al.[40] Hogg et al.,[45] and Watson et al.,[46] suggest that conceptualizing patient experi-ences is complex. Many dimensions were considered for the final Canadian Patient Experiences Survey. This work documented and classified existing patient experiences in PHC surveys and instruments and also provided the foundation for the development of the Canadian Patient Experiences Survey. 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Commonwealth Fund. 2007, 2008, 2009, 2010, 2011 International Health Policy Survey. 2013 [cited 2013 February]; Available from: http://www.commonwealthfund.org/Surveys/View-All.aspx?page=1.83. Haggerty, J., F. Bouharaoui, and D. Santor, Differential Item Functioning in Primary Healthcare Evaluation Instruments by French/ English Version, Educational Level and Urban/ Rural Location. Healthcare Policy, 2011. 7(Special): p. 19.84. Haggerty, J., M-D. Beaulieu, R. Pineault, F. Burge, J-F. Lévesque, D.A. Santor, F. Bouharaoui, and C. Beaulieu, Comprehensiveness of Care from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments. Healthcare Policy, 2011. 7(Special Issue): p. 154-166.85. Haggerty, J.L., F. Burge, M-D. Beaulieu, R. Pineault, C. Beaulieu, J-F. Lévesque, D.A. Santor, D. Gass, and B. Lawson, Validation of Instruments to Evaluate Primary Healthcare from the Patient Perspective: Overview of the Method. Healthcare Policy, 2011. 7(Special Issue): p. 31-46.86. Haggerty, J., J-F. Lévesque, D.A. Santor, F. Burge, C. Beaulieu, F. Bouharaoui, M-D. Beau-lieu, and R. Pineault, Accessibility from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments. Healthcare Policy, 2011. 7(Special Issue): p. 94-107.87. Browne, A.J., C. Varcoe, M. Ford-Gilboe, S.T. Wong, J. Haggerty, et al., Equity-Oriented Primary Health Care Interventions for Marginalized Populations: Addressing Structural Ineq-uities and Structural Violence, 2011, Canadian Institutes for Health Research: BC and ON. UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 38. Appendix8.1. Classification of the Items from the Selected Survey ToolsThis appendix presents the PHC patient experience survey items and responses related to the review of selected surveys. The questions are grouped according to the dimensions of patient experiences in PHC presented in Table 3. 8.2. Access8.2.1.	First	contact	accessibility:	The	ability	to	obtain	patient-	or	client-initiated	needed	care	(including	advice	and	support)	from	the	provider	of	choice	within	a	time	frame	appropriate	to	the	urgency	of	the	problem.Instrument Question Item stem Response categoriesRural	II/III Q21Based	on	your	experience,	how	easy	is	it	for	you	to	get	health	advice	from	your	clinic	over	the	phone?	Not	at	all	easy	/	Not	very	easy	/	A	bit	easy	/	Moderately	easy	/	Very	easy	Instrument Question Item stem Response categoriesPatient	Experiences	Q1Why	did	you	come	to	the	clinic	today?	(Check	all	that	apply)Routine	examination	/	Follow-up	of	a	health	problem/pregnancy	follow-up	/	New	health	problem	/	An	urgent	but	minor	health	problem	/	Prescription	renewal	/	Many	issues	to	discuss	/	Other,	specify______Patient	ExperiencesQ2How	long	did	you	wait	between	making	this	appointment	and	your	visit	today?I	had	a	walk-in	appointment	->	Go	to	question	51	to	2	days	/	Between	2	days	and	1	week	/	1	to	2	weeks	/	2	to	4	weeks	/	4	to	6	weeks	/	More	than	6	weeks	GPAQ	&	NHSQ3How	do	you	rate	this	wait?	Not	acceptable	at	all	/	Not	very	acceptable	/	Moderately	acceptable	/	Accept-able	/	Very	acceptable	GPAQ	&	NHS	Q4How	easy	was	it	to	make	this	appointment?	Very	easy	/	Fairly	easy	/	Not	very	easy	/	Not	at	all	easyGPAQ	&	NHS	Q5How	easy	was	it	to	get	through	to	someone	at	your	clinic	on	the	phone?	Very	easy	/	Fairly	easy	/	Not	very	easy	/	Not	at	all	easy	/	Not	applicableGPAQ	&	NHSQ6How	long	did	you	wait	for	your	consultation	to	start?	Less	than	5	minutes	/	5	to	10	minutes	/	11	to	20	minutes	/	21	to	30	minutes	/	More	than	30	minutes	/	There	was	no	set	time	for	my	consultationCSE-PHC	&	Patient	Experiences	Q20Were	there	times	when	you	had	difficulty	getting	the	healthcare	or	advice	you	needed?No	->	Go	to	question	21	/	Yes,	once	->	/	Yes,	several	times	->	If	yes,	what	type	of	difficulties	did	you	experience?	Difficulty	contacting	a	physician	/	A	specialist	was	unavailable	/	Difficulty	getting	an	appointment	/	Do	not	have	personal/family	physician	/	Waited	too	long	to	get	an	appointment	/	Waited	too	long	in	the	waiting	room	/	Service	not	available	at	time	required	/	Service	not	available	in	the	area	/	Transportation	problems	/	Cost	issues	/	Language	barriers	/	Did	not	feel	comfortable	with	the	available	doctor	or	nurse	/	Did	not	know	where	to	go	(i.e.,	information	problems)	/	Unable	to	leave	the	house	because	of	a	health	problem	/	Other,	please	specify:	_____8.2.2.	Accomodation:	The	relationship	between	how	resources	are	organized	to	accept	clients	or	patients	(including	appointment	systems,	hours	of	operation,	walk-in	facilities,	telephone	services)	and	the	clients’	or	patients’	ability	to	accommodate	to	these	factors	to	realize	access.M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e2 4Instrument Question Item stem Response categoriesQPop Q22Thinking about costs related to your healthcare…In	the	past	year,	did	you	ever	pay	directly	for	any	services	in	your	doctor’s	office?No	/	Yes	->If	yes,	was	it:	Opening	a	file	/	Filling	in	forms	/	Getting	a	sick	note	/	Medical	services	not	covered	by	Medicare	/	Medicine	or	shots	/	Administra-tion	costs,	please	specify:	______Rural	II/III Q23-27In the past year…23.	Were	there	times	when	you	did	not	take	medicines	prescribed	by	a	doctor	because	of	their	costs?	24.	Were	there	times	when	you	did	not	take	laboratory	tests	or	exams	because	of	their	costs?	25.	Were	there	times	when	you	did	not	get	services	recommended	by	your	doctor	that	aren’t	covered	by	health	insurance	because	of	their	costs?	(such	as	physiotherapy,	psychotherapy,	dietetic…)26.	Were	there	times	when	you	found	it	difficult	to	get	health	care	because	you	had	to	take	time	off	work?	27.	Were	there	times	when	you	found	it	difficult	to	get	health	care	services	because	of	the	additional	costs	it	involves?	(babysitting,	parking,	etc.)Never	/	Rarely	/	Sometimes	/	Often	/	Very	often	/	I	don’t	take	any	drugsNever	/	Rarely	/	Sometimes	/	Often	/	Very	often	/	I	did	not	use	any	of	these	servicesInstrument Question Item stem Response categoriesGPAQ	 Q8-11Thinking about your visit today…8.	How	would	you	evaluate	the	amount	of	time	that	the	person	gave	you?	9.	How	would	you	evaluate	the	way	they	listened	to	you	during	the	visit?	10.	How	would	you	evaluate	their	explanations	of	tests	and	treatments?11.	How	would	you	evaluate	the	way	they	involved	you	in	decisions	about	your	care?Very	good	/	Good	/	Fair	/	Poor	/	Very	poorIPC Q12-15Still thinking about the person you saw during your visit today…12.	Did	he	or	she	really	find	out	what	your	concerns	were?	13.	Did	he	or	she	let	you	saw	what	you	thought	was	important?14.	Did	he	or	she	take	your	health	concerns	very	seriously?	15.	Was	he	or	she	concerned	about	your	feelings?	Yes,	completely	/	Yes,	mostly	/	Yes,	a	little	/	No,	not	really	/	No,	not	at	all	CWF Q16-17Still thinking about the person you saw during your visit today…16.	Did	he	or	she	give	you	clear	instructions	about	symptoms	to	watch	for	and	when	to	seek	further	care	or	treatment?	17.	Did	he	or	she	discuss	with	you	your	main	goals	or	priorities	in	caring	for	your	condition?	Yes,	completely	/	Yes,	mostly	/	Yes,	a	little	/	No,	not	really	/	No,	not	at	all8.2.3.	Economic	Accessibility:	The	extent	to	which	direct	or	indirect	costs	related	to	care	impeded	decisions	to	access	needed	care	or	continue	recommended	care.8.3. Interpersonal Communication 8.3.1.	General	communication:	The	ability	of	the	provider	to	elicit	and	understand	patient	or	client		concerns,	and	to	explain	health	and	health	care	issues.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 5Instrument Question Item stem Response categoriesGPAQ Q28Over the past 12 months…How	helpful	did	you	find	the	receptionist	at	your	clinic?	Very	helpful	/	Moderately	helpful	/	Somewhat	helpful	/	Not	at	all	helpfulCAHPS Q29Over the past 12 months…Did	the	clerks	and	receptionists	at	this	clinic	treat	you	with	courtesy	and	respect?	Never	/	Sometimes	/	OftenInstrument Question Item stem Response categoriesIPC Q31-34Over the past 12 months…31.	Did	you	and	your	doctor	work	out	a	treatment	plan	together?	32.	Did	your	doctor	ask	you	questions	about	your	daily	activities	before	deciding	a	treatment	plan?	33.	Did	your	doctor	ask	if	you	felt	you	could	do	the	recommended	treatment	plan?	34.	When	there	were	treatment	choices,	did	your	doctor	ask	you	what	treatment	you	would	prefer?No	/	Yes,	sometimes	/	Yes,	often	/	I	don’t	receive	any	treatment	PACIC Q64Over the past 6 months….64.	When	you	received	care	for	your	chronic	conditions	were	you	helped	to	make	a	treatment	plan	that	you	could	carry	out	in	your	daily	life?	Yes,	certainly	/	Yes,	probably	/	Maybe,	not	sure	/	No,	not	really	/	No,	not	at	all	/	No,	I	haven’t	needed	such	support8.3.2.	Respectfulness:	The	ability	of	the	primary	care	organization	and	practitioners	to	provide	care	that	meets	the	expectations	of	users	about	how	people	should	be	treated,	such	as	regard	for	dignity	and		provision	of	adequate	privacy.	8.3.3.	Shared	decision-making:	The	extent	to	which	patients	are	involved	in	making	decisions	about		their	treatment.Instrument Question Item stem Response categoriesManage-ment		Continuity/PCAS	/	ACESQ35-38About your visits to your doctor/clinic over the past 12 months…35.	Did	your	doctor	or	nurse	seem	to	know	about	your	whole	medical	history?	36.	Did	your	doctor	or	nurse	seem	to	know	about	what	worries	you	most	about	your	health?	37.	Did	your	doctor	or	nurse	seem	to	know	about	your	responsibili-ties	at	work	or	home?	38.	Did	your	doctor	or	nurse	seem	to	know	about	your	personal	values?	Hardly	at	all	/	A	little	/	Moderately	/	A	lot	/	Totally	8.3.4.	Whole-person	care:	The	extent	to	which	providers	address	the	physical,	emotional	and	social	aspects	of	a	patient’s	or	client’s	health	and	consider	the	community	context	in	their	care.M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e2 6Instrument Question Item stem Response categoriesManage-ment	Continuity	Q39-43About ALL the different people that you saw at ALL the different places you got care over the last yearOver the past 12 months…	39.	Were	there	times	when	the	person	you	were	consulting	did	not	know	your	most	recent	medical	history?	40.	Were	there	times	when	the	person	you	were	seeing	did	not	have	access	to	your	recent	tests	or	exam	results?	41.	Were	there	times	when	you	had	to	repeat	tests	because	the	person	you	were	seeing	did	not	have	access	to	results?	42.	Were	there	times	when	the	person	you	were	seeing	did	not	know	about	changes	in	your	treatment	that	another	person	recommended?	43.	Were	there	times	when	you	had	to	repeat	information	that	should	be	in	your	medical	record?	Never	/	Rarely	/	Some-times	/	Often	/	All	the	time	Instrument Question Item stem Response categoriesPCAT Q7	Is	there	a	person	(health	professional)	who	knows	you	best	at	this	clinic?	No	->	Go	to	question	8	/	Yes	If	yes,	is	this	a…A	family	doctor	or	general	practitioner	/	A	nurse	practitioner	/	A	specialist	/	A	nurse	/	Some	other	health	professional	(please	specify)_____Did	you	see	this	person	today?	Yes	/	NoWould	you	say	this	person	is	responsible	for	most	of	your	health	care?	Yes	/	NoPCAT Q30Thinking	of	the	past	12	months,	when	you	went	to	this	clinic,	how	often	were	you	taken	care	of	by	the	same	person?Always	/	Usually	/	Sometimes	/	Rarely	/	Never8.4.2.	Information	continuity:	The	extent	to	which	information	is	used	to	make	current	care	appropriate	to	the	patient	or	client.8.4. Continuity and Coordination8.4.1.	Relational	continuity:	A	therapeutic	relationship	between	a	patient	or	client	and	one	or	more	identi-fied	providers	that	spans	separate	health	care	episodes	and	delivers	care	that	is	consistent	with	the	patient’s	or	client’s	biopsychosocial	needs.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 7Instrument Question Item stem Response categoriesManage-ment	Continuity	Q46About your experiences with any kind of care outside the clinicOver the past 12 months…In	general,	do	you	feel	that	you	your-self	have	to	arrange	the	healthcare	you	receive	from	different	persons	or	places?	No,	the	person	who	follows	my	care	always	does	it	for	me	/	No,	the	person	who	follows	my	care	sometimes	does	it	for	me	/	Yes,	but	it	is	my	choice	to	do	so	/	Yes,	I	have	to	orga-nize	my	care	more	than	I	would	like	/	Yes,	too	much	and	it	is	too	difficult	Manage-ment	ContinuityQ47About your experiences with any kind of care outside the clinicOver the past 12 months…	Thinking	about	all	the	different	persons	you	saw	in	all	the	places	you	went	for	care;	Is	there	ONE	person	who	ensures	follow-up	of	your	healthcare?	No	->	Go	to	question	47	/	Yes	If	yes,	is	this	person	a:	A	nurse	/	A	nurse	practitioner	/	Your	doctor	/	Other	health	professional,	please	specify:	______How	much	does	this	person	keep	in	contact	with	you	even	when	you	receive	care	in	other	places?	Not	at	all	/	Very	little	/	Moderately	/	Quite	a	lot	/	A	lot	How	much	does	this	person	help	you	get	the	health	care	you	need	from	other	places?	Not	at	all	/	Very	little	/	Moderately	/	Quite	a	lot	/	A	lot	How	much	does	this	person	contact	other	health	profes-sionals	about	your	care?	Not	at	all	/	Very	little	/	Moderately	/	Quite	a	lot	/	A	lotManage-ment	ContinuityQ69-71About the person whom you see most at this clinic. Over the past 12 months…69.	How	much	importance	does	this	person	give	to	your	ideas	about	your	care?	70.	How	comfortable	do	you	feel	talking	with	this	person	about	personal	problems	related	to	your	health	condition?	71.	How	confident	are	you	that	this	person	will	look	after	you	no	matter	what	happens	with	your	health?	Hardly	any	importance	/	Only	a	little	/	Moderate	importance	/	A	lot	of	importance	/	Immense	importance	Hardly	comfortable	at	all	/	Only	somewhat	/	Moderately	/	Very	comfortable	/	Completely	comfortable	Not	very	confident	at	all	/	Only	somewhat	/	Moderately	/	Very	confident	/	Completely	confidentPACIC Q63Over the past 6 months…. 63.	When	you	received	care	for	your	chronic	conditions	were	you	encouraged	to	go	to	a	specific	group	or	class	to	help	you	cope	with	your	chronic	condition?	Yes,	certainly	/	Yes,	probably	/	Maybe,	not	sure	/	No,	not	really	/	No,	not	at	all	/	No,	I	haven’t	needed	such	supportPACIC Q65-66Over the past 6 months….65.	When	you	received	care	for	your	chronic	conditions	were	you	contacted	after	a	visit	to	see	how	things	were	going?	66.	When	you	received	care	for	your	chronic	conditions	were	you	encouraged	to	attend	programs	in	the	community	that	could	help	you?	Yes,	certainly	/	Yes,	probably	/	Maybe,	not	sure	/	No,	not	really	/	No,	not	at	all	/	No,	I	haven’t	needed	such	support8.4.3.	Coordination:	The	provision	and	organization	of	a	combination	of	health	services	and	information	with	which	to	meet	a	patient’s	or	client’s	health	needs,	including	services	available	from	other	community	health	service	providers.M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e2 8Instrument Question Item stem Response categoriesManage-ment	Continuity	Q48-50About all the people working at the clinic where your regular doctor see you48.	Were	there	times	when	persons	from	your	clinic	told	you	different	things	(that	didn’t	make	sense	together)	about	your	health?	49.	Were	there	times	when	persons	from	your	clinic	did	not	seem	to	work	well	together?	50.	Were	there	times	when	persons	from	your	clinic	did	not	seem	to	know	who	should	be	doing	what	in	your	healthcare?	Never	/	Sometimes	/	OftenPatient	ExperiencesQ67-6867.	Other	than	your	doctor,	who	else	at	your	clinic	do	you	see	to	manage	your	health	condi-tion?	(Check	as	many	as	apply)68.	Other	than	people	at	this	clinic,	who	else	do	you	see	to	manage	your	health	condition?Only	my	usual	doctor	/	Other	family	doctor	or	general	practitioner	/	A	specialist	/	A	nurse	/	A	nurse	practi-tioner	/	A	nutritionist	or	a	dietician	/	A	physiotherapist	or	an	occupational	therapist	/	A	psychologist	or	a	social	worker	/	complementary/alternative	person	(e.g.,	acupuncturist,	chiropractor,	registered	massage	therapist,	etc.)	Please	specifiy	______	/	Other,	please	specify______Instrument Question Item stem Response categoriesPCAT Q53Over	the	past	year,	who	at	this	clinic	talked	to	you	about	any	of	the	following	subjects?	Check	as	many	as	apply	for	each	subjectYour	doctorAnother	doctor A	nurseSome-one	else	(specify)No	oneImpact	of	healthy	and	non-healthy	foods	on	your	health	Importance	of	healthy	weight	Importance	of	exercise/	healthy	lifestyle	Tobacco	use	on	your	health	Alcohol	or	drug	usePrevention	of	fallsWays	to	handle	family	conflicts	that	may	arise	from	time	to	timePrevention	of	risks	at	work	Instrument Question Item stem Response categoriesNHS	 Q51-52About the care you receive51.	In	the	last	12	months,	has	your	clinic	provided	everything	you	need	to	help	you	manage	your	health	concerns?	52.	In	the	last	12	months,	have	you	had	enough	support	from	local	services	or	organizations	to	help	you	manage	your	health	concerns?	Yes,	definitely	/	Yes,	to	some	extent	/	No,	not	really	/	No,	not	at	all	/	No,	I	haven’t	needed	such	support8.4.4.	Team	functioning:	The	ability	of	primary	health	care	providers	to	work	effectively	as	a	collaborative	team	to	manage	and	deliver	quality	patient	or	client	care.8.5.2.	Health	promotion	and	primary	prevention:	Health	promotion	is	the	process	of	enabling	people	to	increase	control	over,	and	to	improve,	their	health.	Primary	prevention	is	directed	towards	preventing	the	initial	occurrence	of	a	disorder.8.5. Comprehensiveness of Services8.5.1.	Services	provided:	The	type	and	range	of	services	delivered	by	primary	health	care	providers.	This	also	includes	referrals	to	and	from	the	primary	health	care	organization.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 9Instrument Question Item stem Response categoriesIPC	 Q54-58Over the past 12 months…54.	Did	the	person	you	saw	most	at	the	clinic	help	you	feel	that	your	everday	activities	such	as	diet	and	lifestyle	would	make	a	difference	in	your	health?	55.	Did	the	person	you	saw	most	at	the	clinic	help	you	feel	that	you	could	prevent	some	health	problems?	56.	Did	the	person	you	saw	most	at	the	clinic	give	you	a	sense	of	control	over	your	health?	57.	Did	the	person	you	saw	most	at	the	clinic	help	you	feel	that	sticking	with	your	treatment	would	make	a	difference?	58.	Did	the	person	you	saw	most	at	the	clinic	help	you	feel	confi-dent	about	your	ability	to	take	care	of	your	health?	Yes,	definitely	/	Yes,	to	some	extent	/	No,	not	really	/	No,	not	at	allPatient	ExperiencesQ59-62About you and your health59.	How	well	do	you	understand	the	nature	and	causes	of	your	health	problems?	60.	How	well	do	you	know	how	to	prevent	problems	with	your	health?	61.	How	confident	are	you	that	you	can	maintain	the	changes	in	your	health	habits	like	diet	and	exercise,	even	during	times	of	stress?62.	Has	any	health	professional	ever	diagnosed	you	with	or	treated	you	for	any	of	the	following	chronic	health	conditions?	Check	as	many	as	apply.Completely	/	Very	well	/	Moder-ately	/	A	little	/	Hardly	at	all	/	I	don’t	have	any	health	problemsTotally	confident	/	Very	well	/	Moderately	/	A	little	/	Hardly	confident	at	allHeart	disease	/	Arthritis	or	Rheu-matoid	Arthritis	/	High	blood	pres-sure	or	Hypertension	/	Depression	or	Anxiety	/	Diabetes	/	Other	chronic	health	problemsInstrument Question Item stem Response categoriesIPC Q44-45Over the past 12 months…. 44.	How	often	did	doctor(s)	tell(s)	you	about	side	effects	you	might	get	from	a	medicine?45.	How	often	did	doctor(s)	tell(s)	you	what	could	happen	if	you	don’t	take	the	medicine	they	prescribe	for	you?Never	/	Rarely	/	Sometimes	/	Often	/	All	the	timePatient	ExperiencesQ84-8584.	In	the	last	12	months,	have	you	been	given	the	wrong	medi-cation	or	wrong	dose	by	a	doctor,	nurse,	or	pharmacist?85.	In	the	last	12	months,	have	you	been	given	incorrect	results	for	a	diagnostic	or	lab	test?Yes	/	No,	not	that	I	know	of8.6.2.	Patient	safety:	Patients’	or	clients’	reports	of	medication	errors	(given	or	taken	the	wrong	drug	or	dose)	or	incorrect	medical	or	laboratory	reports	and	communication	with	their	provider	about	not	taking	their	prescribed	medication	or	medication	side	effects.8.6. Patient Reported Impacts of Primary Health Care8.6.1.	Patient	activation:	People’s	ability	or	readiness	to	engage	in	health	behaviors	that	will	maintain	or	improve	their	health	status.	M e a s U r i n g  pa t i e n t  e x p e r i e n C e s  i n  p r i M a ry  h e a lt h  C a r e3 0Instrument Question Item stem Response categoriesGPAQ	&	NHSQ18	Thinking about your visit today… Did	you	have	confidence	in	the	doctor	you	saw	or	spoke	to? Yes,	definitely	/	Yes,	to	some	extent	/	No,	not	at	allGPAQ	&	NHSQ19Thinking about your visit today…Did	you	speak	to	any	other	health	care	professional	at	the	clinic	today?No	->	Go	to	question	20	/	Yes	->Please	specify:	Check	as	many	as	applyOnly	my	usual	doctor	/	Other	family	doctor	or	general	practitioner	/	A	specialist	/	A	nurse	/	A	nurse	practitioner	/	A	nutritionist	or	a	dietician	/	A	physiotherapist	or	an	occupational	therapist	/	A	psychologist	or	a	social	worker	/	Complementary/Alternative	person	(e.g.,	acupunc-turist,	chiropractor,	registered	massage	therapist,	etc)	please	specify	____	/	Other,	please	specify	______Did	you	have	confidence	in	this	other	person	you	saw	or	spoke	to?	Yes,	definitely	/	Yes,	to	some	extent	/	No,	not	at	all8.7. TrustAn	expectation	that	the	other	person	will	behave	in	a	way	that	is	beneficial	and	that	allows	for	risks	to	be	taken	based	on	this	expectation.	For	example,	patient	trust	in	the	physician	provides	a	basis	for	taking	the	risk	of	sharing	personal	information.Instrument Question Item stem Response categoriesPatient	ExperiencesQ86-8786.	On	a	scale	of	0-10,	how	confident	are	you	that	you	could	get	the	primary	healthcare	services	you	need?	*Primary	healthcare	services	are	the	ones	we	usually	receive	in	clinics,	doctor’s	office	or	CLSC-not	the	emergency	room	of	a	hospital87.	On	a	scale	of	0-10,	how	confident	are	you	in	your	provincial	healthcare	system?Not	at	all	confident	->	Totally	confident0	/	1	/	2	/	3	/	4	/	5	/	6	/	7	/	8	/	9	/10	8.6.3.	Confidence	in	the	PHC	system:	The	perception	that	allows	patients	to	make	decisions	since	we		assume	(and	expect)	relative	certainty	about	providers	delivering	safe	and	technically	competent	care.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 19. AcknowledgementsThis review on the measurement of PHC patient experiences would not have been possible without the help of multiple experts in the field. First, we would like to acknowledge the contribution of two other teams leading the organizational and practitioner survey instruments.Thanks also to Dr. Jean-Frédéric Lévesque, Cathie Scott, Dr. William Hogg, Dr. Sharon Johnston, Dr. Alan Katz, Dr. Rick Glazier, and Dr. Fred Burge, who reviewed and provided comments on some parts of this report or the Patient Experience Survey. The insights and comments of each of our reviewers contributed greatly to this effort. Their contributions were especially usefull in helping us create the final version of the instrument. Particular thanks go to Analia Rubinowicz, Frances Handley-Derry, Leena Wu, and Dawn Mooney for the contribution of their time in supporting and coordinating the preparation of this report. We also gratefully acknowledge the staff, especially Ali Moses McKeag, Brenda Tipper, and Greg Webster, from the Canadian Institute for Health Information (CIHI) for their support in leading this project, and other PHC research currently underway. This review complements a suite of three practice-based survey instruments for the PHC initiative from the CIHI Primary Health Care Survey project and has been completed in order to support the creation of the Patient Experience Survey. UBC Centre for Health Services and Policy Researchthe University of British Columbia201-2206 east Mallvancouver, B.C. Canada v6t 1Z3tel:  604.822.4969fax:  604.822.5690email: enquire@chspr.ubc.cawww.chspr.ubc.caAdvancing world-class health services and policy research, training and data resources on issues that matter to Canadians

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