The mental health field is undergoing a paradigm shift in which the voice of the consumer is being sought out as the focus shifts to empowerment and two-way communication and away from one-way communication.
Introduction
Collecting critical feedback from customers can help mental health facilities improve their program in a market where clients can choose to seek services elsewhere if dissatisfied. Inviting customer feedback from individuals who have undergone private mental health treatment is a useful tool for improving mental health services in a private nonprofit mental health facility. As Larsen et. al wrote,
… private, nonprofit fee-for-service psychiatric services are consumer dominated. Consumers have a choice as to which facility they seek treatment from. The determination of service quality should be placed in the hands of the clients and relatives.
Surveys are the most common and unbiased way to measure customer satisfaction
Customer satisfaction data that is collected via surveys should be weighed alongside other measures to ensure the evaluation effort is balanced. There are variables that hold the potential to skew any satisfaction data, such as current symptomology and current level of life satisfaction in general. Since the therapeutic process one undergoes in mental health treatment is so closely tied to quality of life, it may be difficult for consumers to separate quality of life from their opinion of the quality of the program.
Despite confounding variables that may skew the results of a customer satisfaction survey, the process of collecting this data is worthwhile for organizations. Any program evaluation process is incomplete and biased if it is missing customer feedback. The mental health field is undergoing a paradigm shift in which the voice of the consumer is being sought out as the focus shifts to empowerment and two-way communication and away from one-way communication.
In order to make recommendations to private nonprofit mental health programs, this post reviews studies that focus on customer feedback surveys and their problems, use, and history in mental health facilities.
Review of the literature
This post reviews literature around three primary topics: types of tools for measuring customer satisfaction with mental health services, variables to consider when collecting satisfaction data, and arguments for collecting satisfaction feedback from consumers of mental health services.
Tools for measuring customer satisfaction
There are a wide range of tools used to collect customer satisfaction feedback after mental health treatment. There is no consensus in the literature on which tool is most valid or reliable. The literature points to a mix of short surveys and interviews as being the most reliable tools for measuring customer satisfaction.
A sample of 100 systematically recruited male and female adults using outpatient psychiatric services at two urban and rural clinics in Southern England were surveyed about what key elements people value in therapeutic interactions. Those key elements were analyzed and reduced to six elements from which researchers produced 40 questions. Those 40 questions were administered to a sample of 30 systematically recruited men and women from the same clinics, asking them to rate the relevance of the questions based on a 5-point Likert scale.
Researchers then reduced the number of questions to 19; these 19 questions resulted in the development of the new PatSat scale. A sample of 44 systematically recruited men and women from the same clinics were asked to take the PatSat scale. The validated and reliable (Ruggeri et. al., 2000) Verona Service Satisfaction Scale (VSSS) was concurrently given to the same group for comparison. Researchers concluded that for measuring customer satisfaction with mental health services, the PatSat was quicker to complete and preferred by patients when compared with the VSSS (Hansen et. al., 2010).
In another study, researchers consulted the literature in order to identify determinants of satisfaction with mental health services. They identified nine categories of satisfaction determinants; for each category they created nine questions. A group of 32 mental health professionals in California chosen for their expertise were asked to rank the nine questions. A preliminary scale was developed and was given to a group of 248 randomly selected mental health consumers in five different service settings. Eight questions emerged which exhibited strong correlations and thus, the Customer Satisfaction Questionnaire-8 (CSQ-8) was developed. The CSQ-8 was then administered to a group of 49 mental health clients selected based on the fact that they had been admitted to the clinic four weeks prior. Analysis of Chi-square statistics and correlations showed that the CSQ-8 possessed a high degree of internal consistency (Larsen, Attkisson, Hargreaves, & Nguyen, 1979).
In a third study, a group of 404 patients with specific diagnoses located in five different European countries were administered the reliable and validated Verona Service Satisfaction Scale – European Version (VSSS-EU). This scale had already been proven to have an excellent overall α of (0.96). A total of 289 subjects completed both the test and the re-test of the VSSS-EU. The re-test data showed that the VSSS-EU was a stable and reliable test for measuring satisfaction with mental health services (Ruggeri et. al., 2000).
The consensus among these studies points to the usage of a validated satisfaction scale as being an effective tool for measuring client satisfaction with mental health treatment.
Variables to consider when collecting satisfaction data
There are complexities present when attempting to gather and measure satisfaction feedback from consumers of mental health services. Mediating variables researchers should consider include current symptomology, current life satisfaction level, and mode of administering the survey.
Ninety-two male and female adult patient volunteers were recruited from two day treatment programs of one community health center in California. Before the CSQ-8 survey was administered, participants responded to the Ladder of Service Satisfaction (LSS) scale. Lastly, the Symptom Checklist-90 (SCL-90) was administered. Researchers found that the LSS correlated highly with the data from the CSQ-8, that symptomology has a low but significant negative relationship with clients satisfaction with services (r = -.40), and that when the survey was administered orally, there was a significant increase (10 percent) in satisfactions level, suggesting the “halo” effect. The “halo” effect occurs when by the very act of asking for feedback in person, a clients’ satisfaction level increases. Researchers concluded that while satisfaction data is important information collect, it is likely mediated by these three variables (LeVois, Nguyen, & Attkisson, 1981).
Eighty-one patients admitted consecutively to a VA inpatient psychiatric hospital in the midwest were administered the Treatment Outcome Profile upon admission to measure symptomology, quality of life, and level of functioning. Upon discharge (average stay was 13.7 days inpatient), they were again administered the Treatment Outcome Profile, this time also completing the fourth section which measures satisfaction level with services. Twenty-nine of the most satisfied and the least satisfied patients were then selected for further study. Researchers concluded that there is a correlation between patient satisfaction levels and other variables. Patients initially reporting fewer symptoms, higher quality of life, and higher level of functioning tended to report a higher level of satisfaction with services upon discharge. Patients with more complex mental health and physical issues tended to be less satisfied with services. An excellent predictor of satisfaction level was self-reported improvement (Holcomb, Parker, Leong, Thiele, & Higdon, 1998).
Former patients (n = 13,541) of various Veterans Administration (VA) Hospitals who were discharged with psychiatric or substance misuse diagnoses were sent questionnaires consisting of 60 questions. A total of 4,968 patients (37 percent) responded. The questions assessed various detailed aspects of the VA hospital and the patients, such as: the atmosphere of the hospital, the therapeutic alliance, age, race, marital status, gender, diagnosis, length of stay, and of course satisfaction levels. The study found correlations between many of the variables. People with physical disabilities tended to be less satisfied overall. Women tended to be less satisfied than men. There was a positive correlation between the patients global health and age and their level of satisfaction. Sixty-one percent of the total variance in patient satisfaction could be attributed to these various patient characteristics. Despite the high percentage of variance attributed to mediating factors, the study finds that collecting satisfaction data is still feasible and informative (Rosenheck, Wilson, & Meterko, 1997).
The consensus among these studies is that there are various mediating variables to take into account when it comes to measuring satisfaction with mental health services.
Arguments for collecting satisfaction data
Private mental health facilities are consumer-driven as clients have a choice as to where they seek services and can leave if dissatisfied. Satisfaction data is worthwhile to collect and organizations are cautioned to not hold these results up as independent measures.
Four-hundred and thirty-three patients from six acute psychiatric wings of two hospitals were administered one question on a Likert scale about satisfaction, were administered the CSQ-8, and underwent a semi-structured interview to assess satisfaction levels with mental health care. This data collection process also took into account variables such as age, race gender, adverse experiences while in the hospital, physical medical issues, diagnoses, and marital status to name a few. The study found that the process of collecting satisfaction data has problems. Patients tend to over-rate their satisfaction despite adverse experiences while in-patient. The study concluded that facilities can improve the delivery of mental health services by taking patient feedback into account (Greenwood, Key, Burns, Bristow, and Sedgwick, 1999).
Researchers recruited 21 volunteer patients from two acute care psychiatric hospitals where average length of stay was 23.38 days. The volunteers were asked to come up with a list of ideal characteristics of inpatient care. Based upon those lists, researchers created a questionnaire and administered this to a new group of 40 patients on the same unit. The questionnaire results were skewed towards positive for satisfaction and researchers found problems with this method of data collection. The focus group approach of this study demonstrates a method of generating criteria for satisfaction from the viewpoint of the patient. The researchers discussed the idea that satisfaction criteria may be unique for each setting and therefore the voice of the patient should be encouraged in expressing what constitutes quality psychiatric care from their perspective (Elbeck & Fecteau, 1990).
Researchers administered a 40-unit self-rated questionnaire that measured patient attitudes about various aspects of care to a group of 173 former inpatient psychiatric patients. Researchers found that greater self-improvement was correlated with higher satisfaction. They also found that certain variables mediated satisfaction level. Researchers concluded that while the area of patient satisfaction has methodological problems, patient satisfaction data may still provide important information in evaluating the quality of care within an organization (Hansson, 1989).
The consensus among these studies is that collecting satisfaction data from mental health consumers can be worthwhile because it can help inform changes and improvement to care.
Conclusion
The field of mental health is turning to an empowerment model that encourages two-way communication between providers and clients. There is solid evidence that supports the collection of satisfaction data from mental health consumers. Anyone collecting satisfaction data should be aware that there are several mediating variables around satisfaction levels, such as symptomology, general life satisfaction, and other medical complications. The use of validated scales and surveys will yield the least biased satisfaction data. Satisfaction data, along with other measures, can and will help to improve mental health services and outcomes.
References
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Greenwood, N., Key, A., Burns, T., Bristow, M., & Sedgwick, P. (1999). Satisfaction with
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Hansson, L. (1989). Patient satisfaction with in-hospital psychiatric care.European Archives of Psychiatry and Neurological Sciences, 239(2), 93-100.
Holcomb, W. R., Parker, J. C., Leong, G. B., Thiele, J., & Higdon, J. (1998). Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatric Services, 49(7), 929-934.
Larsen, D. L., Attkisson, C.C., Hargreaves, W.A., Nguyen, T.D. (1979). Assessment of
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Peterson, R. A., Wilson, W. R. (1992). Measuring customer satisfaction: fact and artifact. Journal of Academy of Marketing Science, 20 (1), pp. 61-71.
Ruggeri, M. (1994). Patients and relatives satisfaction with psychiatric services: the state of the art of its measurement. Social Psychiatry and Psychiatric Epidemiology, 29 (5), pp. 212-227.
Ruggeri, M., Lasalvia, A., Dall’Agnola, R., Tansella, M., Van Wijngaarden, B., Knudsen, H. C., Lesse, M., & Gaite, L. (2000). Development, internal consistency and reliability of the Verona Service Satisfaction Scale – European Version. The British Journal of Psychiatry, 177, pp. 41-48. doi: 10.1192/bjp.177.39.s41.
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