Practice Accreditation and Improvement Survey Report - Swansea … · 2020-05-05 · Montrose VIC...

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Private and Confidential

Mrs Jenny YeoSwansea Road Clinic3 Swansea RoadMontrose VIC 3765

Practice Accreditation and Improvement SurveyReport

Swansea Road Clinic

August 2017

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25 August 2017

Dear Mrs Yeo

Please find enclosed your report outlining your patient feedback from the Practice Accreditation and Improvement survey (PAIS). The results have been illustrated in tables and charts with associated benchmarks, based on feedback given by 513,024 patients to 4,347 Australian general practices. Supporting documents have been provided to help you in the interpretation and understanding of your results.

These results will reflect Criterion 2.1.2 Indicator C.

The format of this highly comprehensive report has been updated, which we hope will provide you with a clearer picture of performance. It is worth spending time to assimilate the detail to obtain the best understanding of your patient feedback.

An Action Plan is included in your Report. Should you wish to use this Action Plan it may guide you in assisting to satisfy Criterion 2.1.2 Indicator D. A "Certificate of Completion" with a Practice Improvement Plan for your practice has also been issued with this Report. This may be of support to you in demonstrating Criterion 2.1.2 Indicator E. We value your feedback and would be grateful for a copy of your Action Plan to help us to develop our high standards and to continue our ongoing commitment to quality improvement.

The data in your report is entirely confidential to your practice. Your anonymised data will be aggregated with data from all other participating practices, and may be used in the generation of national performance benchmarks and contribute to scientific literature regarding the on-going development of standards.

Please contact our staff on 07 3855 2093 or [email protected] if you require further information about your report. We hope that you find the results and feedback a good basis for reflection and that they provide a useful foundation to inform future quality improvements to your practice.

Mrs Zelka HislopManager

PO Box 588 Everton Park

QLD 4053

t: 07 3855 2093f: 07 3355 7047

e: [email protected]: www.cfepsurveys.com.au

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Mrs J YeoSwansea Road Clinic3 Swansea RoadMontrose VIC 3765

Your patient feedback

Distribution and frequency of ratings (table 1) P1

Your mean percentage scores and benchmarks (table 2, graph 1) P2

Your mean percentage scores benchmarked against your FTE GP category (table 3) P3

Your mean percentage scores by domain, benchmarked against your GP FTE category (table 4,5) P4

Your patient demographics (table 6, table 7) P5

Previous scores summary (table 8) P7

Your patient comments P8

Supporting documents

Details of score calculation

Explanation of quartiles

Sample questionnaire

Adding Value to Survey

Action Plan

For a quick review of your PAIS scores and associated benchmarks please turn to page 2 of this report. However, we do recommend reading the entire report to obtain the clearest reflection of your patient feedback

Contents

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Ref: 45868/17377/266

PAIS Practice Report

Your patient feedback

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Ref: 45868/17377/266

Table 1: Distribution and frequency of ratings (questions 1-27)

Distribution and frequency of ratings

Poor Fair Good Very Good

Excellent Blank / Spoilt

Q1 Making an appointment 1 3 17 54 86 1

Q2 Telephone access to a clinician 2 10 26 51 54 19

Q3 Obtaining a home/other visit 2 5 25 44 28 58

Q4 After-hours service 0 4 23 42 29 64

Q5 Seeing clinician of choice 3 13 17 60 62 7

Q6 Consultation and waiting area comfort 0 7 26 63 66 0

Q7 Availability of privacy 0 3 19 53 65 22

Q8 Waiting time in surgery 2 21 45 61 29 4

Q9 Satisfaction with consultation 0 2 15 57 85 3

Q10 Warmth of greeting 0 2 11 53 92 4

Q11 Ability to listen 1 3 10 50 95 3

Q12 Explanations 0 1 13 53 91 4

Q13 Reassurance 0 3 17 51 88 3

Q14 Confidence in ability 0 5 12 51 92 2

Q15 Able to express concerns/fears 0 2 12 60 84 4

Q16 Respect shown to patient 0 2 10 48 100 2

Q17 Time for visit 0 3 16 59 83 1

Q18 Consideration of personal situation 0 2 16 51 91 2

Q19 Concern for patient 0 2 14 51 94 1

Q20 Recommendation 0 4 9 49 95 5

Q21 Reception staff 0 1 10 54 97 0

Q22 Information on fees 0 2 21 61 73 5

Q23 Opportunity for making complaints 1 2 19 48 57 35

Q24 Information on staying healthy 0 2 19 66 65 10

Q25 Reminder systems 1 2 27 44 74 14

Q26 Respect of right to second opinion 0 5 22 47 66 22

Q27 Overall satisfaction with practice 0 2 9 53 93 5

Blank/spoilt responses are not included in your mean percentage score analysis.

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Ref: 45868/17377/266P1

Number of patients providing feedback: 162PAIS Practice Report

Your meanBenchmark data: all practices

mean scores (%) *score

(%)Min Lower

QuartileMedian Upper

QuartileMax

Q1 Making an appointment 84 41 78 84 88 100 Q2 Telephone access to a clinician 75 28 66 72 78 99 Q3 Obtaining a home/other visit 72 21 63 69 75 99 Q4 After-hours service 74 13 65 70 76 99 Q5 Seeing clinician of choice 77 15 74 80 86 100 Q6 Consultation and waiting area comfort 79 31 75 80 85 100 Q7 Availability of privacy 82 44 77 82 86 100 Q8 Waiting time in surgery 65 15 57 65 73 100 Q9 Satisfaction with consultation 85 49 82 87 91 100 Q10 Warmth of greeting 87 44 83 88 91 100 Q11 Ability to listen 87 45 82 87 91 100 Q12 Explanations 87 43 82 86 90 100 Q13 Reassurance 85 45 81 86 90 100 Q14 Confidence in ability 86 45 83 88 92 100 Q15 Able to express concerns/fears 86 35 81 86 90 100 Q16 Respect shown to patient 88 47 85 89 92 100 Q17 Time for visit 84 44 80 85 89 100 Q18 Consideration of personal situation 86 45 82 86 90 100 Q19 Concern for patient 87 46 82 87 91 100 Q20 Recommendation 87 48 83 88 92 100 Q21 Reception staff 88 49 82 87 91 100 Q22 Information on fees 83 28 77 82 86 100 Q23 Opportunity for making complaints 81 36 74 79 83 100 Q24 Information on staying healthy 82 38 76 81 85 100 Q25 Reminder systems 82 31 75 80 84 100 Q26 Respect of right to second opinion 81 23 76 81 85 100 Q27 Overall satisfaction with practice 88 46 83 88 91 100

Table 2: Your mean percentage scores and benchmarks

Your mean percentage scores and benchmarks

*Benchmarks are based on data from 4,675 surveys completed by 4,347 practices with doctors between October 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 513,024 patient questionnaires.See the supporting documents at the end of this report for percentage score calculation and quartile information.

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Your mean score for this question falls in or above the highest 25% of all PAIS mean scoresYour mean score for this question falls in the middle 50% of all PAIS mean scoresYour mean score for this question falls in or below the lowest 25% of all PAIS mean scores

Graph 1: Your mean percentage scores in ascending order of performance with benchmark mean scores from all participating practices

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Ref: 45868/17377/266P2


Your mean Benchmark data (%) (4+ - 6 FTE)*

score (%)

Min Lower Quartile

Median Upper Quartile

Max

Q1 Making an appointment 84 48 77 81 85 95 Q2 Telephone access to a clinician 75 34 64 68 72 86 Q3 Obtaining a home/other visit 72 35 61 66 70 92 Q4 After-hours service 74 37 63 68 72 93 Q5 Seeing clinician of choice 77 46 72 77 81 93 Q6 Consultation and waiting area comfort 79 44 72 78 82 94 Q7 Availability of privacy 82 50 76 80 84 94 Q8 Waiting time in surgery 65 32 54 61 68 90 Q9 Satisfaction with consultation 85 57 81 86 89 96 Q10 Warmth of greeting 87 58 82 87 90 97 Q11 Ability to listen 87 56 81 86 90 97 Q12 Explanations 87 57 80 85 89 96 Q13 Reassurance 85 57 80 84 88 95 Q14 Confidence in ability 86 59 82 87 90 96 Q15 Able to express concerns/fears 86 55 80 85 88 96 Q16 Respect shown to patient 88 57 84 88 91 97 Q17 Time for visit 84 55 79 83 87 96 Q18 Consideration of personal situation 86 57 80 85 88 95 Q19 Concern for patient 87 56 81 86 89 96 Q20 Recommendation 87 58 82 87 90 97 Q21 Reception staff 88 59 80 84 88 97 Q22 Information on fees 83 54 76 79 83 93 Q23 Opportunity for making complaints 81 50 72 76 79 91 Q24 Information on staying healthy 82 54 74 78 81 91 Q25 Reminder systems 82 53 73 77 82 92 Q26 Respect of right to second opinion 81 53 75 78 82 91 Q27 Overall satisfaction with practice 88 58 81 85 89 97

Table 3: Your mean percentage scores benchmarked against your FTE GP category (4+ - 6 FTE)

Your mean percentage scores and FTE GP benchmarks

*Benchmarks are based on data from 627 surveys completed by 603 practices with 4+ - 6 FTE doctors between November 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 104,829 patient questionnaires.See the supporting documents at the end of this report for percentage score calculation and quartile information.

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Graph 2: Your mean percentage scores in ascending order of performance with benchmark mean scores (4+ - 6 FTE)

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Ref: 45868/17377/266P3


Your mean Benchmark data (%) (4+ - 6 FTE)*

Domain** score (%)

Min Lower Quartile


Max

1 - Access and availability 74 39 65 69 73 88 2 - Information provision to patients 82 55 75 79 82 91 3 - Privacy and confidentiality 80 47 74 79 82 94 4 - Continuity of care 79 51 73 77 81 90 5 - Communication skills of clinical staff 86 57 81 85 89 96 6 - Interpersonal skills of clinical staff 86 57 81 86 89 96

Table 4: Your mean percentage scores by domain, benchmarked against your FTE GP category (4+ - 6 FTE)

Your mean percentage scores by domain, benchmarked against your FTE GP category

*Benchmarks are based on data from 627 surveys completed by 603 practices with 4+ - 6 FTE doctors between November 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 104,829 patient questionnaires.See the supporting documents at the end of this report for percentage score calculation and quartile information.

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Your meanMedian benchmark data (%) *

Number of FTE GPsDomain** score

(%)<1 >1 to 2 >2 to 4 >4 to 6 >6 All

1 - Access and availability 74 77 75 72 69 66 72 2 - Information provision to patients 82 85 83 81 79 75 82 3 - Privacy and confidentiality 80 84 83 81 79 76 81 4 - Continuity of care 79 84 82 80 77 74 80 5 - Communication skills of clinical staff 86 88 87 87 85 83 87 6 - Interpersonal skills of clinical staff 86 89 88 87 86 83 87

Table 5: Your mean score and FTE GP (all category) benchmarks

This table has been created to illustrate the difference in scoring achieved by each FTE GP category. The mean percentage scores displayed withinthe benchmark table equate to the median (middle) mean percentage score achieved by all practices within the relevant FTE category. Your FTE GP category has been shaded within the benchmark table.

*Benchmarks are based on data from 4,675 surveys completed by 4,347 practices with doctors between October 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 513,024 patient questionnaires.

**Your percentage mean score for each domain has been calculated based on collated data from groups of questions in this survey (see below).

Domain

1 - Access and availability

2 - Information provision to patients

3 - Privacy and confidentiality

4 - Continuity of care

5 - Communication skills of clinical staff

6 - Interpersonal skills of clinical staff

Questions

1,2,3,4,8

22,24

6,7

5,25

10,11,12,13,15

14,16,17,18,19

Ref: 45868/17377/266P4


Benchmark data (%)*

Number of responses

Your mean score (%)

Min Lower Quartile


Max

Age

Under 25 16 81 36 73 80 86 100

25 - 59 86 84 46 77 82 87 100

60 + 58 82 45 79 84 88 100

Blank 2 -- 29 69 76 83 100

Gender

Female 104 85 46 78 83 87 100

Male 52 79 45 77 82 86 100

Blank 6 88 27 72 79 85 99

Visit with usual clinician

Yes 119 85 49 80 84 88 100

No 35 76 38 73 78 83 100

Blank 8 72 50 72 78 84 99

Years attending

Less than two years 39 79 34 75 81 86 100

More than two years 121 84 49 79 83 87 100

Blank 2 -- 26 69 76 83 99

Table 6: Number of patient responses by demographic category, your mean scores and benchmarks

Your patient demographics (based on those who completed the questionnaire)

*Benchmarks are based on data from 4,675 surveys completed by 4,347 practices with doctors between October 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 513,024 patient questionnaires.-- Score not provided. In the event that there are less than 5 patient responses for any category, the score will not be illustrated.- Benchmark data not availableSee the supporting documents at the end of this report for percentage score calculation and quartile information.Statistical reliability cannot be guaranteed for small numbers but act as a guide.

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Ref: 45868/17377/266P5


Chronic illness or disability Number of responses Percentage of responses

Yes 69 43%

No 89 55%

Blank 4 2%

Speak English at home Number of responses Percentage of responses

Yes 159 98%

No 1 1%

Blank 2 1%

Speak another language Number of responses Percentage of responses

Yes 13 8%

No 145 90%

Blank 4 2%

Born in Australia Number of responses Percentage of responses

Yes 128 79%

No 31 19%

Blank 3 2%

Aboriginal or Torres Strait Islander Number of responses Percentage of responses

Yes 3 2%

No 154 95%

Blank 5 3%

Concession or Healthcare Card Number of responses Percentage of responses

Yes 82 51%

No 74 46%

Blank 6 4%

Level of education Number of responses Percentage of responses

Never attended school 0 0%

TAFE or Trade Certificate or Diploma 60 37%

Primary school 3 2%

University or other Tertiary Institute degree 46 28%

High school 38 23%

Other 13 8%

Blank 2 1%

Your patient demographics (based on those who completed the questionnaire)

Table 7: Number and percentage of patient responses to further demographic questions

Percentages may not add up to 100% due to rounding

Ref: 45868/17377/266P6


Current scores

September 2014

Q1 Making an appointment 84 78

Q2 Telephone access to a clinician 75 64

Q3 Obtaining a home/other visit 72 67

Q4 After-hours service 74 71

Q5 Seeing clinician of choice 77 74

Q6 Consultation and waiting area comfort 79 75

Q7 Availability of privacy 82 81

Q8 Waiting time in surgery 65 61

Q9 Satisfaction with consultation 85 83

Q10 Warmth of greeting 87 82

Q11 Ability to listen 87 83

Q12 Explanations 87 81

Q13 Reassurance 85 81

Q14 Confidence in ability 86 85

Q15 Able to express concerns/fears 86 83

Q16 Respect shown to patient 88 86

Q17 Time for visit 84 80

Q18 Consideration of personal situation 86 83

Q19 Concern for patient 87 84

Q20 Recommendation 87 85

Q21 Reception staff 88 83

Q22 Information on fees 83 79

Q23 Opportunity for making complaints 81 76

Q24 Information on staying healthy 82 76

Q25 Reminder systems 82 77

Q26 Respect of right to second opinion 81 78

Q27 Overall satisfaction with practice 88 85

Previous survey scores comparison

Table 8: Your current and previous mean percentage scores

Ref: 45868/17377/266P7


Your patient comments

From the free text component of the questionnaire.

All comments have been included in their entirety but details which could identify a specific practitioner, practice or patient have been removed to ensure anonymity.

Any comments about how this doctor and/or practice could improve its service?

• Being more able to see your doctor of choice would be good. Long unavailability of doctors not good. Hard having to continually re-establish good relationships with new doctors.

• There are a few doctors with greater skills knowledge than others. A few doctors seen are not adequate in being able to assist with why attending.

• Get rid of the white computer to check in. Patients actually like to speak with reception staff.

• Minimal staff turn overs (doctors).

• A certain doctor was rude.

• It's all very good for me.

• Sometimes it is hard when appointment is running late but to me this means the doctors are thorough. This is more important to me as I would rather the doctors run late and be thorough than just push us in and rush us out.

• I did use the automatic check in machine in my last visit and it didn't work, so I waited for a long time.

• Nil needed.

• Staff are excellent.

• The only way they can improve their service is to keep doing what they're doing.

• Speak louder for elderly patients.

• Remove check in machine.

• Two staff members are all good.

• I am very impressed with the personal care that is taken in all aspects.

• Been coming here for years and would not come back if I was not satisfied. I think one thing I note about the GPs I see is complacency never assume that patient is going to be ok after years of service.

• It is hard to get an appointment with my doctor early.

• They do just great work!

• You are all an excellent team; and play an important part in the ongoing family health care. It has been a very distressing year for the family and you all have played an important roll in helping us get through - with gratitude.

• I've never been able to fault the staff here over years.

• Very happy with my doctor and service.

• I think the practice is very well run and professional.

• I feel the clinic is doing a good job.

• Replicate the practice in more suburbs!

• Availability of appoinmtnet time for unexpected illness.

• Stay as good as you have always been and are we're fortunate to have your TLC.

• Everything is first rate. I am most satisfied at this clinic.

• They don't need to improve - they are excellent already.

• I have no complaints.

• Lose the TV.

• Extended hours, weekend or after hours.

• Remove check in machine.

Ref: 45868/17377/266P8


Your patient comments

From the free text component of the questionnaire.

All comments have been included in their entirety but details which could identify a specific practitioner, practice or patient have been removed to ensure anonymity.

Any comments about how this doctor and/or practice could improve its service?

• Keep it as it is.

• They can't they are brilliant.

• Not much really.

• So friendly.

• Turn down TV.

Ref: 45868/17377/266P9


Supporting documents

0

Ref: 45868/17377/266

The score provided for each question in this questionnaire is the mean (average) value of all of the ratings from all clients who completed the question. It is expressed as a percentage - so the best possible score is 100%.Non-rated responses (Don't know/blank/spoilt) are not used in the score calculations. (A blank response is where a client did not respond to the question and a spoilt response is where more than one tick box option was chosen or the questionnaire was defaced).

Example from your Q1 Making an appointment Total number of responses = 162

Questionnaire rating scale Poor Fair Good Very Good Excellent Non rated

responses

Number of ratings 1 3 17 54 86 1

Value assigned to each rating 0.00 25.00 50.00 75.00 100.00 n/a

(number of Poor ratings x 0.00) + (number of Fair ratings x 25.00) + (number of Good ratings x 50.00) + (number of Very Good ratings x 75.00) + (number of Excellent ratings

x 100.00) =(1 x 0.00) + (3 x 25.00) + (17 x 50.00) + (54 x 75.00) +

(86 x 100.00) = 13575(total number of client responses - number of Non rated responses)

(162 - 1) 161

Your score for Q1 = 84%

In statistics a quartile is any one of the three values that divide data into four equal parts, each part represents ¼ of the sampled population.

Quartiles comprise: Lower quartile, below which lies the lowest 25% of the data. The median, cuts the data set in half and around which lies the middle 50% of the data. Upper quartile, above which lies the top 25% of the data

Question Your Benchmark data (%)*

score (%) Min Lower Quartile


Maximum

Q1 Making an appointment 84 41 78 84 88 1009662

*Benchmarks are based on data from 4,675 surveys completed by 4,347 practices with doctors between October 2012 and February 2016, where each survey had a minimum of 30 questionnaires returned, totalling 513,024 patient questionnaires.

Details of score calculation

Explanation of quartiles

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Ref: 45868/17377/266


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Ref: 45868/17377/266

Ref: 45868/17377/266

Introduction

Although understandable, given workload pressures on general practices, it would be a missed opportunity to view the patient survey as a tick box exercise and one that represents the total patient involvement in the practice. Greater patient engagement in healthcare means having an ongoing relationship and dialogue with patients and welcoming patients as partners in making improvements to services.

Involving patients, via systematic feedback and further discussions, can lead to tangible differences in the quality of the health care experience. Such differences could give you a competitive advantage, as well as within the context of the wider primary care ‘market place’.

Using the survey to improve patient relations

It is recommended that the practice provides feedback to the people who found the time to give their opinions about the service (Criterion 2.1.2E).

There are a variety of ways in which the results of the patient survey can be shared with patients. These include:

• Producing simple posters for displaying in the practice.• Producing a single sheet of A4 summarising the results and placing it on the notice board.• Publication of an ‘easy to read’ one-off newsletter available in the practice for patients to take

away. This would include ‘headline findings’ and could act as an invitation for anyone wishing to work with the practice to implement any changes resulting from the survey.

• Publication of the results of the survey on your website, if you have one. This can also have provision to ask for further feedback and ideas about changes.

• A one-off meeting to explain the findings to an invited group of patients.• Setting up a group, including practice staff and patients, to discuss the results and agree

methods of communicating results to other patients. This ‘critical friends group’ could develop an ongoing action plan to implement changes.

Using the survey to improve your own practice

Just doing the survey does not in itself bring about future improvement in scores. Rather, such improvement occurs only when there is a concerted effort by practice staff to put into action strategies which are targeted at specific areas in need of change.

The survey can act as a baseline measurement, which in subsequent years can be used to show whether improvements have been made.

Using the survey to develop services

Comments received in response to the survey - and possibly followed up with a ‘critical friends group’ - may give you ideas for new services that you may wish to provide.

Adding Value to the Survey

Ref: 45868/17377/266

The following questions are designed to help the practice staff reflect on the results of the patient survey, and to think about things they may do differently as part of continuous quality improvement.

Don’t rush to conclusions or actions. A dedicated team meeting is a good way to provide all staff with an opportunity to reflect on the results, and discuss findings that are particularly interesting or confirm things you suspected.

We would encourage you to develop a clear action plan by responding to the questions below.

Look at your mean percentage score for each question (found on page 2), your domain scores (found on page4), and compare your scores to the national benchmarks.

In addition, review your written patient comments.

Action Plan

1. Which are the areas where the practice is performing strongly? Are you pleased with these scores and why?

Areas where the practice is performing strongly

Your brief commentary

1.

2. Which are the areas where the survey identified the greatest potential for improvement? What actions might you take to improve performance? Look for practical and realistic actions.

Areas where the survey identified the greatest potential

for improvement

Your brief commentary Action taken to improve performance

2.

3.

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2.

3.

Ref: 45868/17377/266

3a. Did the practice staff discuss the results of the survey?

YES NO

b. If YES, how and when was this done?

c. If YES, who was involved? (roles of people, not names)

4a. Did the practice provide information to patients based on the results of the survey?

YES NO

b. If YES, how was this done?

5a. How useful have you found the patient feedback results in gaining a better understanding of how to approach quality improvement activities in your practice?

Poor Fair Good Very Good Excellent

b. Please comment

6a. Please rate your overall experience of carrying out this survey

Poor Fair Good Very Good Excellent

b. Please comment on both positive aspects and areas you feel could be improved

Ref: 45868/17377/266

Certificate of Completion

This is to certify that

Swansea Road Clinic3 Swansea Road

Montrose VIC 3765

has completed the

Patient Feedback Surveyon 25 August 2017

conducted by

CFEP Surveys

Assoc. Professor Michael Greco Julie McGovern

We listened to you…and weare improving patient care

At Swansea Road Clinic we carried out a patient survey (the Practice Accreditation and Improvement Survey) and asked for your honest opinions on the service we provide. We listened to your concerns and have taken the following actions in order to make improvements to patient care where you feel it would be most useful:

What you told us What we have done

1.

2.

3.

4.

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The results of this survey will help us toprovide the best possible service to you

Patient Experience Survey Results 2017

Swansea Road Clinic

"Striving towards excellence"

Thank you for your participation in this survey

of all patient ratings about this practice were good, very good or excellent

97%

The pie chart percentages may not add up to 100% and the good, very good and excellent sections may not equal the total value shown due to rounding.

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