 patient’ (Table 4). Cronbach’s alpha coefficient of the first domain was 0.85. The alpha coeffiecient of the second domain was 0.60,,and the alpha coefficient of the third domain was 0.42. The item-total correlations of the third factor were below 0.40. The internal consistency did not increase by taking an item out of this third domain.
The second analysis was performed on 52 items. Reliability analysis showed that the questionnaire contained four domains with Cronbach’s alpha coefficients above 0.70, and one domain with an alpha coefficient of 0.67. The five domains had an explained variance of 51%. Like the first analysis, this second analysis fulfilled the predefined criteria; Eigenvalue > 1 and KMO = 0.837. However, Bartlett’s test of sphericity was not significant (p = 1.00; N = 298). Domains, items and Cronbach’s alpha coefficients are presented in Table 5. All item-total correlations were above 0.40, with the exception of the item ‘consistency of provided information’. The Cronbach’s alpha of the domain remained the same if the item was left out. The five domains covered 24 items.
N/A Not applicable due to one remaining item after deletion.
For every item the experience score and quality improvement score were computed. Within the top 20 of most important quality aspects, four aspects stood out as far as their improvement potential was concerned: ‘information on side-effects of the medication’, ‘information by healthcare professionals on danger signals to watch out for after leaving the A&E’, ‘information by healthcare professionals on readmission in case of health problems’, and ‘availability of parking space near the A&E’ (Table 2). Three out of four items were dealing with information needs at the end of the A&E visit, and belonged to the 14 items with the highest improvement scores, i.e. a quality improvement score >1; range 0–4 (Table 6).
I importance score (range: 1–4), Q quality improvement score (range: 0–4), E experience score (range: 1–4).
The aim of this study has been to construct and test a questionnaire to measure patients’ experiences with the accident and emergency department, according to the guidelines of the Consumer Quality index. This first version of the Consumer Quality index for the accident and emergency department (CQI A&E) consisted of 84 questions. 52 questions were phrased as ‘experience questions’. The response rate (47%) of the pilot test was comparable to other postal surveys involving A&E patients [14, 19]. However, disease-specific CQ-indices showed better response rates (68%–84%) [2, 6, 7, 20, 21]. To determine the construct of the questionnaire, two exploratory factor analyses were performed. The first analysis was performed including thirteen items. Three domains were constituted (‘attitude of healthcare professionals’, ‘environment and impression of the A&E’, ‘respect for and explanation to the patient’). A second analysis comprising all 52 experience questions was performed with the aim of including more questions on experiences deemed important by patients. Five domains ‘attitude of healthcare professionals’, ‘information and explanation’, ‘environment of the A&E’, ‘leaving the A&E’, and ‘general information and rapidity of care’ were constructed, covering 24 items. Two out of three domains in the first EFA were internally consistent, whereas all domains in the second EFA were internally consistent. Internal consistency of domains increases by increasing the number of respondents. Despite of lower response numbers in the domains of the second EFA, the internal consistency exceeded the internal consistency of the first EFA. The percentage of explained variance of the five domains decreased five percent compared to the explained variance of the three domains of the first analysis.
Two main goals for CQI-data can be distinguished. The first goal is to compare quality of care between healthcare providers. A strict (following the CQI-guidelines), statistically correct EFA was performed in order to generate the information needed for making a valid comparison between A&Es. Researchers, the Health Care Inspectorate, health-insurance companies, hospital boards and the Ministry of Health are the intended users of these outcomes. However, the main customer in healthcare is the patient. Therefore, the second goal is to acquire the information needed for quality improvement within a healthcare institution. To this end, an alternative EFA was performed. To include more content of the questionnaire in the domains, more questions were added. We think this information may help A&E managers and others to start evaluating quality improvement projects. Both goals represent a different way of constructing domains in questionnaires. Following all criteria in the CQI guidelines, domains are constructed using the perspective of a reflective measurement model [22, 23]. Only items with a 4-point Likert scale were included. Items that did not fit into any domain, and domains that did not fulfil the statistical criteria, were omitted. The qualitative phase was carried out in order to detect all aspects related to healthcare performance in the A&E. Each aspect is a unique part of the provided care and together they form the construct ‘quality of care’. To end up with a few statistically related items neglects the broad range of the aspects. Therefore, a formative measurement model may be better suited to construct domains in experience questionnaires. The latter theory concerns the construction of domains based on content and not solely on strict statistical criteria. In the second analysis, we did not try to construct domains solely from a formative perspective, but we tried to include as many experience questions as possible, while still achieving internally consistent and interpretable domains. We included all domains that came up in the second EFA, thereby doubling the content of the questionnaire included in internally consistent domains. Although we only relaxed one of the criteria of CQI-guidelines, we think that these domains are better suited for quality improvement and that they are also suited for benchmarking. The improvement scores provide concrete tailor-made information, which can be helpful for management and staff.
In accordance with most CQ-indices, the domains on communication, information, attitude of healthcare providers (often within the communication domain) and the environment of the health service, are part of the CQI A&E. Domains regarding accessibility and leaving the organisation are also often found [6, 7, 20, 25]. There are a lot of similarities to other CQI instruments, whereas the similarities with satisfaction questionnaires are few. The A&E satisfaction questionnaire Quality Patient Perspective discussed patient participation. The Swedish A&E Patient Satisfaction Survey revealed 3 factors: caring, teaching and clinical competence.
The most important aspects in healthcare performance in the A&E from the patient’s perspective dealt with competence of professionals, hygiene and expectations. It has to be determined whether these importance scores are valid across study populations.
In an English importance study, with 16 participants who had visited the accident and emergency department the most important aspect was confidence and trust in the doctors and nurses. Secondly, ‘being treated with respect and dignity’, and thirdly ‘explanation about condition and treatment’ were important items. Interestingly, waiting time did not feature in the top 20 of most important aspects in our study. As regards the top three of least important aspects, our study concorded with the English study on aspects such as refreshments in the waiting room and not being asked details about the patient’s condition or illness too often. However, in the English study the number of respondents was limited, and inclusion criteria broader.
The study has same limitations. Firstly, we used the pilot study dataset of respondents of only one hospital. In the next phase of the development, the stability of the domain structure will be assessed in a dataset of 20 A&Es, and therefore the presented domains are preliminary outcomes. The discriminative capacity of the CQI A&E will be assessed in that phase as well. Secondly, in this study a consecutive sample was used for the psychometric analysis. All patients who had visited the A&E within an average week were included. The gender and age profile of the respondents was representative for the A&E population of the research hospital. Respondents and non-respondents were comparable as regards age, gender, day or time of attendance and symptoms. Therefore, it is unlikely that the low response rate has affected the outcomes. A significant difference between both groups was found for the triage code. The least severely injured patients (blue triage code) were underrepresented within the respondents group. These patients are often discharged without experiencing all aspects of healthcare performance and perhaps did not think of themselves as a ‘true’ A&E patient. This might have introduced selection bias among respondents.
The study protocol had advantages such as sending the questionnaires to the patient’s home, instead of administering them in person in the A&E, which prevents selection bias caused by healthcare professionals. Also, all patients received the questionnaire within one week after their A&E visit, which limits the recall bias. However, patients’ symptoms might have evoked recall bias.
The Consumer Quality index for the accident and emergency department measures patients’ experiences of A&E healthcare performance. Preliminary psychometric characteristics of the CQI A&E are good, but further research on reliability and validity is needed. Depending on the viewpoint, exploratory factor analysis results in two or five internally consistent domains. The 5-domain structure seems preferable, as this includes more content of the questionnaire while maintaining internal consistency. Furthermore, the improvement scores of each item provide information that makes it possible to identify aspects that require consideration in order to increase quality of care. The preliminary outcomes and the discriminative capacity have to be confirmed in future research by means of the CQI A&E.
R.K. Stellato, MSc. has contributed substantially to the analysis and interpretation of the data.how these activities relate to the course objectives found in section 14 of the