Wait a minute…

Yesterday I thought a lot of patient experience vs patient satisfaction and I felt I was going in circles – round and round and round. Made me dizzy! Today, I come to think of it again… The thing is, I think I got it… Funny enough, it was my dysfunctional marriage (2017) that gave me the final clue.

Early in life many of us learn to lower our expectations in an attempt to reduce the chances of getting disappointed, right? It’s kind of a life hack – to go around with not too high expectations and then when you least expect it to happen, it surprises you, and – voil√†! – suddenly you’re extremely happy and satisfied. Just because you had no expectations and this experience was more then you expected ūüôā If you for example have high hopes and expectations on your marriage and believe it’s going to be like in the romantic comedy films, then you (sadly) probably going to experience something else and be¬†terribly disappointed.

Consider these two scenarios:

  1. The patient is an anxious younger woman and she expect the colonoscopy to be painful and embarrassing and in the end it turns out to be quite “OK” since the sedation made the pain go away and also added a bit of amnesia. Given those circumstances, we can suspect the experience of the colonoscopy in this case to be over expectations and a pretty “good” experience. We have a satisfied patient.
  2. The patient hasn’t heard anything negative about colonoscopy and has a strong believe in the health care system. There will be no need for sedation since the patient is a calm elder male. Under the procedure, at the end of it, he gets nausea and hypotension due to¬†visceral pain. It all goes away in 2-3 minutes but the patient ends up with a feeling of betray and loss of control. This patients experience was not align with the expectations and it ended up with an unsatisfied patient.

The conclusion: The satisfaction is closely connected with the expectations of the experience. Research on satisfaction much include both expectations and experiences meanwhile research on experiences can “stand alone”. Regarding my choice, the focus must be on the experience instead of satisfaction!

You made it clear to me, Stefan. Thank you for marrying me 16 (long) years ago!

My dysfunctional marriage (ongoing)¬†Real life marriage. Yours 4ever and ever… and ever, until death do us part, Sweden.

Photo: Pixabay

New dimensions

Still trying to adapt to my “new” life as a PhD student. The hardest part is to prioritize which “task of the day” I’m should lay hold of. There are so many of them… so how do I select them in a good, structured and effective way? I find myself doing list of what I’m about to do… spending time to organize my tasks instead of actually do them. But I’m doing “things” all the time, every day of the week and still… it is not enough. Every so often, I think I’m on the wrong path but then I remember that the path never is straight forward. The path is supposed to be winding and that the path is the journey and that the process have to take time… and then I’m back in my loop again, trying to figure out what to do next. Maybe a blog post…?

Earlier I wrote about six dimensions of quality, according to the report “Crossing the quality chasm”. Today I’ve learned about new dimensions but this time it is regarding “Patient satisfaction”. Ware et al. (1978) argued for 8 dimensions of patient satisfaction in a proposed taxonomy:

  • Art of care
  • Technical quality of care
  • Accessibility/convenience
  • Finances
  • Physical environment
  • Availability
  • Continuity of care
  • Efficacy/outcome of care

It amaze me that some truths still remains. The taxonomy is complex and two weeks ago I got the suggestion or may I say an advice not to center my attention towards patient satisfaction and instead focus on patient experiences since it is an “easier” topic to define and thereby study. I’m in an early stage of my research and now, I have the opportunity to choose, so obviously¬†I’ve been thinking a lot of this ever since.

I looked attitude up on the internet and is says “A settled way of thinking or feeling about something“. Our expectations is “A strong belief that something will happen or be the case“.¬†My instant thought is that this must be very individual, I mean which attitude and what expectations we have. And then we experience something “An event or occurrence which leaves an impression on someone” and perceive it “A way in which something is regarded, understood, or interpreted“. ¬†Again, extremely¬†individual how an event is interpreted by my attitude. So were does satisfaction fit into all this? The internet says that satisfaction is “A fulfillment of one’s wishes, expectations, or needs, or the pleasure derived from this“. I don’t know about this pleasure thing according to my research topic, colonoscopy, but definitively needs. This is align with Cleary & McNeil (1988) who states that patient satisfaction builds upon the individuals needs.¬†So, is a patient satisfied if their individual needs are fulfilled? Then I have to identify which needs are the most common to patients undergoing a colonoscopy in order to know if the patients is satisfied with the experiences from the procedure, right? Easy Peasy!

Or… Why not choose satisfaction, why is experiences (and for that matter needs) “easier”? Is experiences more single dimensional? Maybe, I don’t have to go all the way around…? Some may define patient satisfaction in the gap between the patient expectation and the actual experience (Beattie et al., 2015). There are many definitions of patient satisfaction and one reasonably definition is made by Maciejewski et al. (1997) who suggests that it represents:

“A patient’s cognitive or emotional evaluation of a health care provider’s performance and the evaluation is based on relevant aspects of the patient’s experience.”

I guess I’m back with patient experience. I realize that yet another task for me, is to define patient experience.¬†One way to consider patient experience is in terms of the determinants (factors) of the experience, its components and/or the outcomes of the actual experience (de Silva, 2013). In the report de Silva refers to a study by Lau et al. (2012) who¬†indicates the need of, not only focusing on the experience but also ask patients about their levels of experience and how they want to see it improved.¬†I believe I’m back again with the outcome – patient satisfaction…

*BIG sigh & rolling my eyes*

Beattie M, Murphy DJ, Atherton I, Lauder W, (2015) Instruments to measure patient experience of healthcare quality in hospitals: a systematic review. Syst Rev, 23, 4:97.

Cleary P, McNeil B, (1988) Patient Satisfaction as an indicator of quality for care. Inquiry. 25, 25-36.

de Silva D, (2013) No 18: Measuring patient experience. Evidence scan, The health foundation.

Lau RL, Gandhi R, Mahomed S, Mahomed N, (2012) Patient satisfaction after total knee and hip arthroplasty. Clin Geriatr Med, 28(3), 349-365.

Maciejewski M, Kawiecki J, Rockwood T, (1997) Satisfaction in understanding health care outcomes research. Gaithersburg, Aspen Publishers Inc.

Ware J, et al. (1978) The measurement and meaning of patient satisfaction: a review of the literature. Health Med Care Serv Rev. 1(1), 3-15.

Photos: Pixabay

A siren call

The first course that I participate in, as a PhD student, is a course in psychometric, and it will last the whole semester. I have to travel approximately 1,5 hour to get there since it’s located in another part of the county I live in. I wake up at five o’clock and try to go to bed early (before I fall asleep standing…). I have to say, it is such a positive experience. All the participants are friendly and they seems to be competent in their areas. Not to mention our teachers, who are immensely skilled! I feel blessed to get the¬†opportunity to take part in this course of study.

Yesterday we talked about validity and reliability and today, in the morning, our focus was factor analysis. After lunch we started to practice what we’ve been lectured about. Basically, we sat in front of computers trying to estimate different psychometric tests. It was hard but also lots of fun!

Now and again, during these two days I have felt the urge of laughter, not knowing what to think, what to do or say… Occasionally, I’ve been completely lost. Still, in the middle of this misleading trip of psychometric chaos, I’ve manage to redirect myself, past latent variables and dichotomous items toward the water surface. And guess what I found deep down in the ocean? I found a theory who called for me like a siren from the Greek mythology. Don’t think the siren is a dangerous creature but presumably precarious and definitely challenging. The theory that I discovered is called “Item response theory” (IRT) and these videos will cradle me to sleep tonight… Zzzzz…

Photo: Pixabay

Dangerously tangled

Right now, I aim to enhance my PhD project plan and in this work I’m desperately seeking structure. I have lots and lots of articles (and they’re continuously increasing), on my desk, in my backpack, on the toilet, on the bedside table, even in my laundry. They’re possibly everywhere – all over the place.

Emily Sparkes have done and shared a brilliant infographic in her Twitter account, demonstrating my (and obviously others) dilemma.


How on earth will I ever get this straight? I’ve tried to do numerous of tables in word and several excel sheets but nothing seems to give my an overview of the different pieces and how they fit (or not fit) together. My new strategy is to try mind-mapping. A few years ago I gained acquaintance with Coggle and since then I have a penchant for this excellent and free (!) tool. To structure all the articles is a hard and time consuming work but to my contentment and absolute joy, the use of different colors are now free. This makes my experience surprisingly more pleasant. Hopefully, this mind-mapping will help me unravel my article chaos.¬†I cross my fingers!


Photo: Pixabay


According to me, as a Swede, vulnerable and especially¬†vulnerability is kind of difficult to pronounce. It¬īs like there¬īs too many¬†vowels way back in my throat… I have to concentrate hard to get it right. The last days I¬īve been concentrating hard, really hard. My first deadline was today and in agreement with my supervisors I have sent my revised project plan to them. I will get my feedback when we meet Thursday afternoon. Yesterday a feeling of fear emerged into my consciousness, fear of showing my weaknesses and flaws to three supervisors that I look up to, respect and admire. A fear that almost paralyzed my¬†intellectual capabilities. A fear which had¬†power of my thoughts and made me feel inferior and¬†fragile. After a sleepless night and hours of brooding I¬īve come to the conclusion that in order to improve my academic skills I have to accept the process of uncover myself to my supervisors. There will no longer be any doubts of which level my critical thinking is at. That is the price I have to pay for expose my capacity and abilities. In some ways I¬īm terrified to show this¬†manifestation of competence (worst case scenario – incompetence) but I also think that I have to embrace the¬†adeptness and just lay myself bare and show my stomach in order to get better. You know, like dogs do, totally¬†unabashed by the position their in.¬†Only, unlike the dogs, I¬īm utterly embarrassed by my posture. Nevertheless, it is what it is, no harm done – yet – I have to trust my supervisors and I am grateful for their feedback! The response will make me grow and improve. After all I¬īm here to germinate.

Ambition for the rest of the day: To endeavor a jaunty walk into the sunset!


Photos: Pixabay

Cognitive process

Sometimes it helps to make a bad joke out of those odd moments in life. At the interview (when I applied to become a PhD student) one associate professor asked me a question and it has haunt me ever since.



Also me: OMG, I don¬īt even understand the question!

But I do have questions – lots of them…

  • What is so special about this specific group of patients that I want to study?
  • How does their experiences differ from other group with similar preparations?
  • Why is this research important and what is the future value?
  • …and so on…into infinity.

Before the summer I agreed with my supervisors to study the subject gastroenterology in-depth so that I would have the prerequisite skills¬†to enhance my research project when I see them in one week from now and here I am making memes… Back to finding focus and answers!

Photo: Pixabay


Six dimensions

According to the report “Crossing the quality chasm” from 2001, there are six dimensions of quality. These dimensions¬†represent¬†characteristics of how health care should be and what areas to focus on when improving it.

  • Safe – make no harm
  • Effective – evidence-based care
  • Patient-centered – individual responsive and respectful care
  • Timely – access and system responsiveness
  • Efficient –¬†cost effectiveness
  • Equitable – same quality to everyone

I think that Jessica Uriarte makes the six dimensions understandable in her excellent video.

In the video Jessica talks about how to honor the patients¬īexperiences and that all care must be align with their goals and values.¬†Not unexpectedly that is in line with what the report¬†Crossing the Quality Chasm has declared:

“Patient-centered encompasses qualities of compassion, empathy,
and responsiveness to the needs, values, and expressed preferences of the
individual patient.”

Health care should focus on adapted care that is flexible and aware of the specific needs of individuals to provide patient-centeredness.

Quality improvement is a process of continually evaluating clinical practices using patient outcomes as the basis of evaluation. Berwick (2002) argues for patients‚Äô outcomes as the fundamental source of defining quality. By ignoring the patients¬īexperiences and perceptions we could end up with a care that is inhuman, out of compassion and¬†empathy. Instead we should honor the patients¬ī needs and take their goals and values into account when striving towards high-quality care.

I believe that the core in my forthcoming research will be to highlight the patients perspective. To put it in a nutshell, it seems to be impossible to conduct high-quality endoscopic procedures without taking the patients¬ī experiences into account.

Berwick D (2002) A User’s Manual for the IOM’s Quality Chasm Report. Health Aff (Millwood), 21(3), 80-90.

Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington, National Academy Press.

Uriarte J (2015) 6 dimensions of Healthcare Quality. https://youtu.be/QexTk38euzY


From good to great

Oh dear, what have I done? Today¬īs lesson is nothing less than an understanding of the¬†impossible thing I¬īm about to do. How on earth am I going to measure patient satisfaction during endoscopic procedures? My ambition is to achieve a standard for measuring patient satisfaction in the name of quality assurance and by that create a tool for quality improvement.

Fred Lee in this TEDx talk is excellent and fun when he describes an experience of taking a blood sample. (Let me get this straight – I don¬īt fancy Fred Lee¬īs old fashion description of him being a manly male and us being female nurses categorized into gentle vs. rough but if you see beyond that I totally get his point.) So this is how it goes, at first he meet “the good nurse” rough Rudy who concentrates on her task and accomplish it without any vital errors. Afterwards he describes another encounter with “the great nurse” gentle Cherie. She mastered the task of taking a blood sample in a different more compassionate way, where she cared for the person in front of her. The patient, Mr Lee¬īs perception of the two meetings was an example of how good went into great and of course he want caring gentle Cherie to come for tomorrow mornings blood sample.

He also makes an¬†comparison with a trip to Disney world… it was good but not fun. Guess we all want a trip to Disney world to be more than good and, if I¬īve understood the point of this video, we in the health care business ought to think the same. Our patients are supposed to experience something satisfying in their encounter with us.


The father of quality – Edward Deming – is quoted in the video:

If you can¬īt measure it, you can¬īt improve it. But, the most important figures one needs for management are unknown and unknowable.

The question of how do you measure the effort of going from good to great in patient perceptions still remains and that will be my headache for eight looong years ūüėČ

Photo: Pixabay

Today’s lesson

Today I¬īve learned about quality improvement in health care. It all started with the desire to answer the questions: What is patient satisfaction and why does it matters? One thing led to another and as I started my search I went back in time, way back to 1966, where I met Avedis Donabedian (1919-2000). Apparently, he is the father of the leading paradigm quality framework, which I am quite familiar with. The framework who describes the dimensions of care in; structure, process and outcome. The structure is described as the staff, the access and the equipment, while the process is the action, for example diagnosis and treatment. Finally, the outcome reports about the result, which can be both objective or subjective, as well as individual or group wise. Donabedian advise researchers to use¬†the question -What goes on here?¬† rather then¬†-What is wrong and how can we do better? I think that can be a great¬†suggestion and a healthy reminder to take into account when I design my research questions. Also inspired by David Feinberg and his UCTV-talk about patient experience where he simply asked patients at the UCLA hospital using the question -How is the care?¬†I believe that an open mind and a¬†spirit of inquiry must be the best approach to explore the endoscopic care process and the patients experiences of it.

Donabedian A (2005)¬†Evaluating the Quality of Medical Care.¬†The Milbank Quarterly, 83 (4), 691‚Äď729. Milbank Memorial Fund, Blackwell Publishing.

Feinberg D (2012) Quality Improvement and Healthcare Reform: Patient Experience with David Feinberg. University of California Television(UCTV). https://youtu.be/RKLkmzrhzvI 

Photo: Pixabay

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