Improving patient feedback: making revalidation more meaningful

Published
12 Nov 2018

12 Nov 2018

Interacting with patients is central to doctors’ day-to-day work, and to their professional development. However, there is much room for improvement in the current processes used to generate patient feedback. Consultant endocrinologist Dr Nick Lewis-Barned, education research fellow Mr Don Liu and chief registrar Dr Shuaib Quraishi discuss the recommendations from a new RCP report.

Following an extensive consultation involving doctors from a range of specialties, patients, lay representatives, responsible officers and appraisers, the RCP has published Improving patient feedback for doctors.1 This report is also a forwardlooking response to the ndependent review of revalidation undertaken in 2017 by Sir Keith Pearson for the MC.2 The review calls for an invigoration of the purpose of patient feedback and a more sophisticated, technology-supported approach to collecting, analysing and making use of this information.

Revalidation in the UK requires doctors to collect patient feedback using standardised questionnaires once in a 5-year revalidation cycle. However, this frequency provides only a brief and occasional snapshot of a doctor’s professional skills, and is not enough to influence practice.

Too few patients are involved in giving feedback on an individual doctor – between 20 and 50 depending on the questionnaire being used. For many doctors this represents fewer than 1% of all patients seen in a 5-year period. These issues are compounded by the limited scope of the information currently being generated, ie semi-quantitative rating scores on a doctor’s communication and interpersonal skills.

In general, there are doubts as to whether the current process provides useful feedback for a doctor’s professional development, which is one of the main intentions of appraisal and revalidation. Since feedback is not seen as useful, some doctors are tempted to treat the process as a ‘tick-box’ exercise and give superficial regard to the feedback collected.

During my recent review of medical revalidation for the GMC, many people spoke enthusiastically about how feedback from patients helps doctors to develop their insight. But I also heard concerns that we are not giving as much weight to the patient voice as we should. Methods for gathering feedback are often limited or not easily accessible; patients are not given sufficient information or support; and doctors are not getting enough quality feedback to be able to reflect meaningfully on what they are doing well and where they could improve. Our ambition should be greater.1
Sir Keith Pearson – independent chair of the former GMC Revalidation
Advisory Board

Problems also exist for patients who are giving feedback. In a busy hospital, a patient will interact with many people, and may have difficulty recalling the individual doctor the feedback is intended for. This may lead to the misattribution of feedback. When providing their feedback, patients may also be influenced by how services (not just clinical) have been delivered by other individuals/teams or the healthcare organisation. Patients tell us that they want to provide feedback to help doctors with their professional development, but are limited to giving only semi-quantitative rating scores on a set number of professional skills and attributes, rather than comments from their own experience.

These are only some of the problems associated with the current patient feedback process – more are considered in the report. The focus of this report is to set out options for improvement. Rather than gathering feedback being a once in 5-year requirement, the report recommends discussing patient feedback annually at appraisal (already the case for continuing professional development). For this to happen, much more, and more frequent, feedback will need to become normal for doctors. Feedback can be collected continuously during an appraisalcycle through an open invitation to patients, and also in a planned and intentional way that reflects the range of patients seen by a doctor. As well as semi-quantitative rating scores, qualitative feedback could be collected in the form of free-text comments and personal narratives through paper-based tools, online platforms and face-to-face or group interviews with patients.

To avoid increasing – and perhaps to decrease – the burden on individual doctors, the options set out in Improving patient feedback for doctors calls for healthcare organisations to develop effective systems and infrastructure to collect, collate, analyse and report on patient feedback about individual doctors. Central to this will be the harnessing of IT. The extensive use of the internet and ownership of mobile devices makes online collection of feedback realistic, using software to personalise questionnaires to reflect the clinical encounter and display in ways that are helpful to patients, eg use of large fonts and symbols for the visually impaired. Software is already available allowing computer-mediated analysis of qualitative information. This makes managing large volumes of free-text comments and personal narratives from patients possible in an automated way using human-initiated algorithms, which allow the detection and classification of different sentiments and feelings, both positive and negative, expressed by patients about their doctor.

The organisational patient feedback model suggested in the RCP report also recommends identification of dedicated staff (patient feedback champions). These are already employed in many NHS trusts, and promote and manage feedback processes in their organisation. They can also be critically important in proactively engaging patients from seldom-heard groups. An example of this is directly helping those with cognitive and/or communication difficulties or who have problems writing due to arthritis, tremor or other health problems.

Attention also needs to be paid to other seldom-heard groups (eg frail older people, homeless people and those whose first language is not English) who are currently under-represented in healthcare feedback processes due to actual or perceived barriers in giving or obtaining this information. This is not just an issue of equality; the seldom-heard represent a large proportion of all patients, often have the greatest health needs and arguably are best placed to feed back on the quality of their healthcare experience.

The improvement options in the report will need to be piloted and tested. It is proposed that this is done at selected healthcare sites over the next 5-year revalidation cycle. One of the aims will be to ascertain the costs relative to the benefits of these options. Sufficient investment is needed if patient feedback is to be done really well and be influential for doctors’ professional development, appraisal and revalidation.

Improving patient feedback for doctors can be downloaded from the RCP website. For more information or to share your thoughts email: revalidation@rcplondon.ac.uk 


References

  1. Royal College of Physicians. Improving patient feedback for doctors. London: RCP, 2018.
  2. Pearson K. Taking revalidation forward: improving the process of relicensing for doctors. London: GMC, 2017.

Key recommendations from Improving feedback for doctors 

Recommendations are interconnected and are grouped into five key themes:

1. Purpose of feedback and engaging doctors and patients – It should be made clear to doctors and patients that the primary purpose of the feedback process is to support reflection and professional development and stimulate clinical excellence. It is not a pass–fail assessment of doctors.

Patient feedback should be discussed annually at appraisal. In those instances where doctors have no patient or carer contact the requirement for patient feedback in revalidation can be omitted. This omission should be agreed during the doctor’s annual appraisal.

2. Frequency, amount and representativeness of patient feedback
– Feedback should be in real-time (provided at or close to the time of interaction) and sought continuously through an open invitation to all patients.

Feedback should also be intentionally sought every year from a proportion of patients seen by the doctor. The sample of patients should be evenly distributed throughout an annual appraisal cycle and be representative of the doctor’s portfolio or scope of clinical practice. Patients from seldom-heard groups should also be represented for whom bespoke feedback tools and processes may be required.

3. Types of patient feedback – Semiquantitative rating scores (eg 1–6, very poor to very good) provided through patient feedback questionnaires on a doctor’s interpersonal and communication skills remain a useful source of information for appraisal. More bespoke questionnaires will need to be developed for some specific patient groups and in clinical settings where feedback may be difficult.

In addition, ways to collect and record qualitative feedback should be developed and piloted. Free text comments, personal narratives and descriptive feedback from patients about individual doctors can be useful for professional development and appraisal.

4. Developing an effective organisational infrastructure – The increased scale, frequency and types of feedback, and need to collate, analyse and report this information more frequently, can only be addressed by healthcare organisations harnessing IT. The use of IT should be part of a system approach adopted by organisations which also makes use of dedicated and trained staff – patient feedback champions and appraisers – in supporting patients giving and doctors receiving and using feedback. Key to the development of an effective patient feedback infrastructure will be the active support of and organisation’s senior leaders and managers.

5. Developing and piloting new feedback processes – A programme of work should be undertaken over the next 5-year cycle to develop, pilot and test the processes, tools and organisational infrastructures necessary to deliver patient feedback to the quality envisaged in the report. This will require sufficient investment but should be viewed in the wider context – of greater patient involvement in their healthcare, in stimulating doctors’ professional development, and benefiting other healthcare professions seeking to implement their own systems of revalidation that in part involves patient feedback. An important next step is to engage with non-medical stakeholders in healthcare to ensure a coordinated approach is taken