Design
This was an observational study of response to a postal survey of patient satisfaction that was instituted as part of a quality improvement program in a local EMS system in 2001. This study was approved by the University of Cincinnati Institutional Review Board.
Setting
We evaluated the patient satisfaction survey distributed by Reading Fire and Rescue, Reading, Ohio. The city of Reading consists of 11,292 residents and approximately 1,200 EMS runs are carried out per year. The 2000 U.S. Census data indicates that the population is 93.7% white and 3.2% African American. The median per-capita income for the city is $23,527. The patient satisfaction survey was mailed to patients who were evaluated and transported between January 1, 2001 and December 31, 2004. Patients were not sent a survey if they were nursing home residents, were dead on arrival, had sustained cardiac arrest, had no mailing address or were known to be homeless. Patients with multiple runs during a single survey mailing period were sent only one satisfaction survey.
EMS system
The EMS system in use at Reading Fire and Rescue is a paramedic first responder system, i.e. the first personnel on the scene are Emergency Medical Technicians – Paramedic (EMT-P). After the EMT-P crew assesses the patient, they determine whether transport to a hospital is required and, if so, by what level of care; patients can be transported by EMT-P, or by EMT-Basics, or a combination of these. Patient acuity is used to determine the combination of EMS personnel used for transport.
Patient satisfaction survey
The survey instrument used is shown in Figure 1. The survey was designed to be brief and to assess two primary domains of satisfaction: interaction and communication, in addition to overall satisfaction. The emphasis on interactions and communication was based on previous EMS-based research highlighting problems in this area [7,8]. Five quantitative questions were included that used a standard 5-point Likert scale, anchored by 'very satisfied' and 'very unsatisfied'. Two of the questions assessed personal interactions between EMS providers and patients, two assessed communication, and the fifth was a global satisfaction measure. (Figure 1). In addition, three qualitative questions were included to provide patients an opportunity to express concerns about care, suggestions for improvement, and to identify the most important factor affecting how the patient felt. Open ended questions also allow assessment of domains incompletely captured by structured questions, and can result in higher reports of elements of care that are dissatisfiers [9].
The patient satisfaction survey methodology was designed to be simple to implement on a routine basis, and to require minimal resources to conduct. The survey questions were printed on the back of a postage-paid, pre-addressed postcard, and the postcard was mailed to potential responders. An anonymous methodology was selected; this maximizes the likelihood of patients reporting dissatisfaction or problems [10], and can improve response rates [11]. The benefits of increased reporting of problems that can be addressed was considered to outweigh the benefits of being able to assess response bias.
Surveys were printed at a local shop in batches of 1000 as needed. The fire department lieutenant was responsible for getting the printing done. The lieutenant was also responsible for labeling and mailing of the surveys. This was done once every month. All patients or, for patients aged less than 18 years, their guardians, served by the EMS system during the previous month were identified from an electronic database that is used to capture run information. Names and addresses were printed on labels and mailed using the United States Postal Service. Neither the time from the run to the mailing, nor from the mailing to response was assessed. Completed surveys that were mailed back to the fire department were collated, interpreted, and reported by the lieutenant as needed for the purposes of the quality improvement program.
Data management and analysis
Returned satisfaction surveys were provided to the investigators identified only by year of service. A summary description of patients served by the EMS system was also provided to contextualize results. Survey data were entered into Microsoft Excel (Microsoft Corporation, Redmond, WA) for subsequent analysis using SPSS v 13.0 (SPSS Inc., Chicago, IL). Open ended questions were categorized independently by two physicians familiar with the EMS system. The qualitative question relating to concerns was categorized as no answer, no concerns, and concerns noted. The question relating to the most important action to improvement how the patient felt was coded as no answer, interpersonal communication, response time, technical care, or some other action. The question pertaining to what could have been done differently was coded as no answer, nothing, or an identifiable change could be made. Cohen's kappa was used to assess the agreement in coding between the two physicians. In the case of disagreement, the most conservative (i.e. negative) response was allocated.
Response rates were computed as simple proportions and the 95% confidence intervals (95CI) of the proportions were computed using the score method. Response rates were compared between years using the Chi-square test. Secondary analysis was conducted to estimate the cost of conducting this patient satisfaction survey. The fire department lieutenant was interviewed to determine man hours spent on the quality improvement program. He was questioned as to hours he spent per month printing, labeling and mailing the survey. He was also questioned as to the hours he spent collating, interpreting, and reporting the results of returned surveys. The physical cost of each survey was determined by a combination of postal rates during the time of the study and printing costs.
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