Quality Improvement Specialists' Experiences of Implementing an Assessment of Patients' Experiences in South Korea
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ORIGINAL ARTICLE ISSN 1225-9330 (Print) | ISSN 2288-4955 (Online)
J Korean Acad Nurs Adm (간호행정학회지) Vol. 28 No. 1, 1-8
https://doi.org/10.11111/jkana.2022.28.1.1
Quality Improvement Specialists' Experiences of Implementing
an Assessment of Patients' Experiences in South Korea
Hwang, Jeonghae1 · Park, Eun Young2 · Kim, Bok Nam3 · Kim, Moonsook4
1
Professor, Department of Health Administration, Hanyang Cyber University
2
Associated Professor, College of Nursing, Gachon University
3
Associated Professor, Department of Nursing, Daegu Health College
4
Director, Nursing Department, Seoul National University Hospital
Purpose: The aim of this study was to explain the patient assessment experiences of the medical staff responsible
for customer satisfaction and quality improvement at their respective medical institutions. Methods: This was a
qualitative study using a focus group with quality improvement or custom service department managers. Participants
were selected using purposive sampling. Data collection was conducted with seventeen participants divided into
three focus group interviews from July 3 to 5, 2017. Each interview took an average of 1 hour and 40 minutes.
Transcribed data were analyzed using qualitative thematic analysis. Results: Base on the analysis, four categories
and eight themes were derived. The categories were: 1) what is the quality of hospital service? 2) between
directionality and timeliness, 3) variations in recognition and application, and 4) changing in hospital culture
Conclusion: The assessment of patient's experience has spread a patient-centered culture and elicited significant
changes in the behavior of medical and hospital staff. However, the survey instruments and procedures for assessing
patient experiences need to be continuously improved, and additional research is required to secure evidence related
to patient experiences.
Key Words: Focus group; Hospital; Qualitative research; Quality of health care
of quality of health care and an essential component of
INTRODUCTION
health care system performance assessment.
Patient-centred healthcare starts from a changed per- A patient experience assessment (PEA) is a survey that
spective [1,2], which is to break away from traditional ill- evaluates the degree of patient-centred care at a medical
ness-oriented healthcare and to understand the patient as site, such as a patient satisfaction survey. In many coun-
an individual with unique value. Patient-centred is gen- tries, customer satisfaction surveys have been conducted
erally defined as 'respecting the desires, needs, and prefer- to assess patient-centred healthcare. In January 2017, the
ences of patients in the decision-making process by build- Health Insurance Review & Assessment Service (HIRA) in
ing partnerships between care providers, patients, and pa- Korea started a trial implementation of the assessment
tients' families and ensuring education and support that service and systems [4]. In July of the same year, the first
patients need to make decisions and participate in their PEA was conducted in earnest. The first PEA conducted
own care' [3]. Patient-centred medication (regardless of by the HIRA was for patients who were discharged from
whether or not it achieves the goals it aims to achieve, such the general hospital [5]. The questionnaire consisted of 24
as improving the quality of health care and improving questions in six areas, including nursing and medical
health levels) itself is considered essentially the right thing practices, medication and treatment processes, the hospi-
to do. Patient-centred is considered to be a key component tal environment, and patient rights. The survey was con-
Corresponding author: Park, Eun Young
College of Nursing, Gachon University, 191 Hambangmoe-ro, Yeonsu-gu, Incheon 21936, Korea.
Tel: +82-32-820-4603, Fax: +82-32-820-4201, E-mail: parkeunyoung@gachon.ac.kr
- This research was supported by the Korean Society on Patient Safety & Quality Improvement Nurses (KoSQIN).
Received: May 16, 2021 | Revised: Nov 8, 2021 | Accepted: Jan 7, 2022
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ⓒ 2022 Korean Academy of Nursing Administration http://www.kanad.or.krHwang, Jeonghae · Park, Eun Young · Kim, Bok Nam et al.
ducted by telephone. The assessment results correct the experience of quality improvement (QI) specialists who
distribution in consideration of different patient config- have experience applying PEA (PEA) to hospitals.
urations by hospital and yield comparable patient experi-
ence scores by hospital [6]. Therefore, the PEA, which 2. Participants
identifies experiences during hospitalization, is reported
to be more descriptive of differences in practice by hospi- Participants were selected using purposive sampling by
tal than the patient satisfaction survey, which examines e-mail among the members of the QI Society. E-mails were
the patient's expectation and satisfaction [7]. sent to members in charge of quality management work-
It is reported that positive patient experience is related ing in hospitals that received a trial evaluation of patient
to increased hospital profitability [8], which directly af- experience medical institutions, and seventeen of them
fects hospitals and shows higher nursing service satisfac- agreed to participate.
tion and hospital reuse than patients who receive Customer
Experience Management (CEM) [9]. In the future, hospitals 3. Data Collection
will be paid medical quality support costs from the gov-
ernment based on the results of the evaluation. Therefore, Data collection was conducted through three focus
hospitals are making various efforts to provide patients' group interviews from 3 to 5 July 2017. Interviews ranged
experiences more positively. from one hour to two hours and ten minutes. The focus
The experiences of healthcare providers during the ear- group consisted of 7 to 10 participants with rich experi-
ly days of shifting from disease-centred to patient-centred ences related to the application of the research theme [13],
healthcare have important implications for the Korean that is, PEA. The focus interview was conducted with
medical community. The PEA will induce a change in the semi-structured questions. The first question started with
medical culture [9], and it will be necessary to look at the 'Please tell me about your patient experience evaluation
experience of the process as well as its consequences [10]. preparation and evaluation process experience'. Focus
Quality improvement (QI) specialist is a mainstream nurse group interviews were conducted with 2~3 researchers
dedicated to quality management in hospitals, who pro- participating, and we served as interviewers and field
poses a service delivery system to efficiently provide inter- observers. Immediately after the interview, we performed
dependent medical field work, and plays a role in commu- an initial analysis with the interview contents and field
nication for cross-professional cooperation and coordina- notes.
tion [11]. A holistic understanding of QI specialist's experi-
ence in patient experience surveys is thought to contribute 4. Data Analysis
to the development of the theory of cooperation and coor-
dination in nursing practice. Transcribed data were analysed using six-stage qual-
The FGI study has advantages [12], such as, it helps at- itative thematic analysis by Braun and Clark [14]. All inter-
tain an understanding about complicated PEA situations views were transcribed by a trained research assistant.
and identify major theme or variables affecting PEA in the Analysis was performed concurrently with data collec-
hospitals. This study attempted to explore and to provide tion. We re-read the data to familiarize ourselves with it.
an explanation for the experiences of the quality improve- Thereafter, we generated the codes, which were pithy la-
ment activities regarding PEA. These efforts will demon- bels achieved through capturing both a thematic and con-
strate the difference between patient satisfaction surveys ceptual reading of the data in the transcripts. To search for
and patient experience surveys in the practice of the medi- themes, we compared the similarities and differences in
cal field, and how changes are occurring in the attitudes the code and categorized them into similar semantic units.
and perceptions of health professionals after applying the We reviewed the themes in relation to the entire extracted
PEA that were observed. This study will provide an op- dataset, created a detailed analysis, identified the essence
portunity to discuss the direction for a more valuable PEA. of each theme, defined and named the themes for further
discussion of themes. Finally, we wrote an analytic narra-
tive and contextualized it.
METHODS
The analysis process was carried out manually by our
1. Study Design research team. We shared and discussed our experiences
and opinions regarding data collection and analysis via
This qualitative study used focus groups to explore the email. Three researchers possess prior knowledge of QI
2 Journal of Korean Academy of Nursing AdministrationQuality Improvement Specialists' Experiences of Implementing An Assessment of Patients' Experiences in South Korea
activity in hospital, and two researchers are experts in con- themes. We also tried to maintain neutrality throughout
ducting qualitative research. the research process.
5. Ethical Considerations RESULTS
Prior to conducting the research, this study passed the 1. Participant Characteristics
research ethics review of the university (HYCU-IRB-2017-
001-1) with which the researcher is affiliated to ensure the The participants in this study were those who were di-
human rights of participants. We obtained written con- rectly involved in the PEA at the hospital where they
sent from the participants, after explaining the purpose worked, and all but two were nurses. All participants had
and procedure of the study. They were also informed that at least three years of QI-related work experience (Table 1).
the data would be used for research purposes only and
the recordings and manuscripts would be kept on a single 2. Themes
locked computer.
After analysing the focus group interviews, the four
6. Ensuring Rigor in Research themes and eight sub-themes were derived. Four themes
are: 1) what is the quality of hospital service? 2) between
For ensuring rigor in this study, we applied the criteria directionality and timeliness, 3) variations in recognition
proposed by Sandelowski [15]; reliability, fittingness, au- and application, and 4) changing in hospital culture (Table
ditability, confirmability. The data of this study reveals the 2). These themes were illustrated the QI specialists' experi-
actual experiences of the QI specialist. The FGI were re- ences to implement of 'patient's experience' in hospital.
corded and transcribed verbatim. We tried to ensure the
accuracy of the transcriptions by comparing the record- Theme 1. What is the quality of hospital service?
ings with the transcriptions. We also identified the ad- This theme was a major concern for participants as they
equacy of citations to support themes derived from the prepared and conducted multiple hospital service assess-
data. The participants' narratives were described and in- ments as heads of quality management departments.
terpreted based on the derived themes. We read the manu- Their concern about myth for quality of a hospital, it was
script multiples times and clearly described the analytical including not only the result of the treatment of a disease,
procedures for deriving initial codes, sub-themes, and but also about the tenderness and kindness associated
Table 1. General Characteristics of Participants (N=17)
Age Number of Total working period in Total overall working
Group Occupation Department
(yr) hospital beds current department (yr) period (yr)
Group 1 53 Nurse QI ＞500 12 29
38 Nurse QI ＞500 9 15
44 Nurse TFT ＞500 14 20
46 Administrative staff CS ＞1,500 3 28*
47 Nurse CS ＞1,000 5 26
52 Nurse CS ＞500 17 27
Group 2 54 Nurse CS ＜500 10 31
47 Nurse TFT ＞1,000 8 24
50 Nurse QI ＞500 5 27
44 Nurse QI ＞500 10 17
45 Nurse CS ＞2,000 19 23
48 Nurse CS ＞1,500 20 26
Group 3 56 Nurse CS ＞1,000 13 33
48 Nurse QI ＞1,000 14 28
55 Nurse QI ＞500 13 19
44 Administrative staff CS ＞1,000 5 7*
43 Nurse QI ＞2,000 7 20
QI=Quality improvement; CS=Custom service; TFT=Task force team; *At the current hospital.
Vol. 28 No. 1, 2022 3Hwang, Jeonghae · Park, Eun Young · Kim, Bok Nam et al.
Table 2. Themes of Experiences for Application of Patients Experience Evaluation in Hospital Assessment
Themes Sub-themes
What is the quality of hospital service? Can assess the nature of the hospital service?
Relationship between treatment outcome and patient experience
Between directionality and timeliness Direction of evaluation
Timeliness
Variations in recognition and application Practitioners' interests and efforts
Hospital administrators' awareness and support
Changing in hospital culture Authenticity of patient contact
From doctor-centred to patient-centred
with healthcare. This included concerns about how the hospital assessments, and reflects their concerns. Partici-
treatment, care, and nursing of patients were reflected in pants said that there is a need to reflect on considerations
the quantitative assessment and whether society's require- regarding the inherent function and nature of the hospital
ments of healthcare delivery were fulfilled. and the culture of excessive assessment in our society.
Quality of medical service should be supported by Because the quality of medical care that patients
the quality of care, because the results from the pa- feel is to perceive the nature of our hospital as quality
tients are not all good when they are discharged. As I in a distorted way, the hospital assessment or say, the
have experienced, is it probably the result of the final CS satisfaction survey, I thought these were the big-
feeling that the patient or family has in our hospital, gest rats for us. - FGI 3
the feeling of communicating with the staff in the hos-
pital or the facility or is it a feeling for the entire hospi- Theme 2. Between directionality and timeliness
tal? ... I thought it might be the last feeling left in my Participants who were involved in institutional assess-
head which becomes the last experience that de- ments or demonstrations of processes that need to be fol-
termines the quality I feel in the hospital. - FGI 3 lowed prior to the implementation of the PEA agreed to
move to the patient-centred approach. However, some
(1) Relationship between treatment outcomes and patient participants raised questions about not considering the
experience Korean culture, not giving adequate time to the hospitals
This was drawn from the participants' concerns about so that they could be prepared, and about the validity of
the influence of patient outcomes and stories about the some of the published assessment items. Most participants
hospital assessment. Many concerns were expressed that said that they should begin to change the hospital culture
the patient's experience during hospitalisation could de- to become patient-centred and to accept that this is the be-
pend on the outcome of the disease. The patient's treat- ginning of change.
ment outcome is the most influential factor on the assess-
ment rather than the level of the hospital. It's the right that inserting the experience of a pa-
tient's position into the quality of medical institutions
From a patient's point of view, good treatment fits the trend of the times, but let's do a little bit of as-
prognosis might be quality? If looking at it from the sessment now and connect with it later. As a result,
patient's position, with good operation, and when I assessments are more urgent than hospitals worrying
came up with what I expected, it didn't matter wheth- about real concerns and the patient's treatment
er I was waiting or the issue of doctors. Just when I quality. I don't think the patients want it. I don't think
became a patient, when treated for it and then it feels I'm going to forget about the essence of it in this day
better and then you feel something like everything is and age. - FGI 1
happy? - FGI 1
(1) Direction of assessment
(2) Can assess the nature of the hospital service? This theme was derived from the participants who ap-
This was a question that the participants in charge have plied for the PEA at each hospital from the time they were
constantly asked themselves while undergoing numerous ready to apply, agreeing to changes in the assessment
4 Journal of Korean Academy of Nursing AdministrationQuality Improvement Specialists' Experiences of Implementing An Assessment of Patients' Experiences in South Korea
where a patient-centred emphasis was placed. Although condition? So I think it's a result of giving up on a
implementation was prematurely started, most partici- hospital that what I feel during the assessment is that
pants agreed with the change that emphasised a patient- the results will be something to give up on a hospital
centred focus. that can't work well and to give support to a few hos-
pitals that are doing well. - FGI 3
The survey itself is actually turning into a survey
that can change the doctors, nurses, or behaviors we (1) Practitioners' interests and efforts
provide, compared to my previous satisfaction. ... In All the participants had been in charge of quality man-
order to get better results, we have to move the doc- agement for many years. Some participants were over-
tors and move the nurses, and then something changes whelmed by the task of responding to hospital assess-
even if it changes into something better. In the proc- ments from several institutions each year, while others
ess, I think then it is possible to head towards an as- were still preparing for a new round of assessments.
sessment that could change some people: the hospi-
tal's medical staff. - FGI 2 Our quality management is [about] what's going
on, such as electrical wiring behind the fluorescent
(2) Timeliness lights, how efficient and safe it is, and I'm very inter-
This theme emerged from most participants arguing ested in this. But the patients here are interested in
that public relations should be considered prior to apply- whether it's a fluorescent lamp or a chandelier. - FGI 2
ing the PEA. Patients whom the participants met while ap-
plying the PEA had difficulty in separately evaluating (2) Hospital administrators' awareness and support
their treatment outcomes from the hospital experience The level of awareness of the hospital management ex-
and lacked much understanding of the difference between ecutives was also important in the application of PEA. The
medical service satisfaction and assessment. Nevertheless, perception of management executives was that the PEA
all participants agreed that it is an appropriate time to was a new version of a consumer satisfaction assessment
change the PEA. and it was accepted as an obligation or formal convention.
However, many participants said that the active support
I hope there is something commercially available of management had the greatest impact on the outcome of
in our country, and I think this is a little better than the application of PEA.
the existing satisfaction survey. Didn't we make this
come in too soon when you introduced this? I think Theme 4. Changing in hospital culture
[so]. - FGI 2 This theme was derived from the fact that all partic-
ipants who applied the PEA to each hospital expressed
Theme 3. Variation in recognition and application that the culture of hospitals was changing to patient-cen-
This theme was derived from the fact that the percep- tred, through the application process and subsequent re-
tion of patients' experience assessments varies. The appli- sults. Several hospitals have already improved many as-
cation varies depending on the degree of support for the pects of their hospital's culture, but it was noted that
hospital's interest and quality management, as well as the changes are emerging at the point of contact with the phy-
level of awareness and concern about the hospital's assess- sician closest to the nature of the medical service. This is
ment. not just a matter of service but also of authenticity; the
There were differences in the size and tasks of the qual- medical staff is constantly engaged in modifying the space
ity management departments of hospitals. In addition, the for the patient, and provide nursing care for the patient
understanding and support provided by the management during the patient's stay at the hospital. The participants
and medical directors differed among hospitals. There were told that the changes in physicians were particularly
were some participants who were already preparing for noticeable, especially when providing the PEA on the
the PEA, while others responded to it prior to the change phone.
in the QI system in the hospital.
Experience assessment seems to have made a great-
Is there any variation in each hospital and various er progress in care than in satisfaction. It seems to
conditions are different? Wouldn't it be dangerous to have been research that changed the culture. It was a
just disclose the discrimination by reflecting it as one meaningful first hospital assessment but there was a
Vol. 28 No. 1, 2022 5Hwang, Jeonghae · Park, Eun Young · Kim, Bok Nam et al.
limit to [the] changing of staff attitudes inside the safety, effectiveness, timeliness, efficiency, and equity as a
hospital, and in that aspect, experiences seem to come requirement for healthcare. [3] In the healthcare service as-
and so we look at the patient experience or satisfac- sessment, the patient-centred approach has long been the
tion from a new perspective. - FGI 3 subject of patient satisfaction surveys, and recently the pa-
tient's experience of assessment has become a major area
(1) Authenticity of patient contact of hospital services [17,18]. Previous studies have in-
Minor but important changes were made at the point of dicated that in various assessments, medical institutions
contact with the patient, such as making eye contact, pro- still lacked a response to the needs of patients [7,19,20]. A
viding explanations slowly, and clarifying the patient's patient-centred approach is difficult to provide in the
questions. This change has been communicated sincerely medical field. Medical care service is such an area where
to the patients by the hospital staff. In particular, the the biggest change is expected through the PEA.
change in doctors was a great change for the patients. Healthcare service assessment and accreditation sys-
Until this change, quality managers had made a long- tems were implemented to ensure that hospitals would
standing effort to improve the quality of their hospital provide high-quality medical services [21,22], and health-
culture. It resulted in an opportunity to recognise the sin- care staff have acknowledged that accreditation has had a
cerity of the doctors towards the patients. positive effect on QI [22-24]. Although the patient-centred
approach is at the centre of this accreditation, there is con-
(2) From doctor-centred to patient-centred cern that a fair assessment may be difficult because pa-
Participants said that the biggest change experienced in tient-centredness cannot be independent of the effects of
applying the PEA was to move the focus of the hospital patient preferences and the underlying diseases. When the
from doctors to patients. This paradigm shift at the centre patient experience becomes a major focus of hospital as-
of hospital culture is natural, and it is this part that must be sessment, the emphasis shifts to the consequent patient ex-
accepted and changed in the medical culture in Korea. perience questions, rather than the veridicality of the pa-
They seemed to be proud that the beginning of the hospi- tient experience [25].
tal's transition from the doctor to the patient was reflective The subjectivity of satisfaction cannot be completely
of what was happening in the field. overcome by objective experiences, and the fairness of
the assessment cannot be ensured. The quality of health-
As we get this pre-assessment now, all we have to care is defined by the times and existing institutions. In
do is throw away the idea of looking at the patient particular, the quality of patient experiences and the path
[as] we used to, and put them in our chest and heart through which such experiences are gained must be shared
as a person that should be respected. I think doctors by all members of the healthcare system. Unlike satisfac-
are facing this challenge ... I think it's this assessment tion, which is the outcome indicator, experience includes
that makes them challenge that. - FGI 2 the context of process indicators, such as the patient's ex-
perience with service performance and frequency, and it is
more objective [17].
DISCUSSION
Assessment is also important for the precision and val-
The results drawn from this study encompassed three idity of the tool, but acceptance depends on the procedure
areas. First, QI specialists in charge of PEA recognised pa- and method used. Since the purpose of evaluating patient
tient-centredness as a critical area in medical institutions experience was to evaluate services between hospitals,
via this PEA. Second, they pointed out that the current much confusion arose due to improper corrections in
evaluation system does not properly evaluate on-site ex- areas that are difficult to evaluate, or where the evaluation
perience due to the limitation of experience evaluation score is significantly lower, such as in the doctor's section
tools, and future improvement is necessary. Third, the [21]. It is necessary to reflect on whether the current tools
PEA included objective statements about providing medi- for the PEA are adequately included [26].
cal services and specific information on QI compared to To overcome the limitations of the PEA in previous sat-
the patient satisfaction survey; however, subjective factors isfaction surveys must be improved. First, there are con-
could not be complete eliminated. cerns about the validity of the items in the PEA. Priority
The patient experience is a representative quality as- should be given to what the patients want in healthcare
sessment area viewed as patient-centred [16]. The US Ins- rather than the ease of assessment. Institutions with good
titute of Medicine proposes a patient-centred service with outcomes in PEA should be able to clearly interpret why
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