LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0
J Nurs Care Qual
Vol. 25, No. 4, pp. 344–351
Copyright c 2010 Wolte...
LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0
Seeking Patient Feedback: Dimension of Quality in Cancer Care 345
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LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0
Seeking Patient Feedback: Dimension of Quality in Cancer Care 347
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Seeking Patient Feedback: Dimension of Quality in Cancer Care 349
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Seeking patient feedback an important dimension of quality in cancer care

  1. 1. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 J Nurs Care Qual Vol. 25, No. 4, pp. 344–351 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Seeking Patient Feedback An Important Dimension of Quality in Cancer Care Meghan L. Richard, MSc, RN; Monica P. Parmar, MSc, RN; Paula P. Calestagne, BA; Lynne McVey, MSc, RN A patient satisfaction survey was conducted with ambulatory cancer patients to identify areas that they consider priorities for change. Wait times and telephone contact with healthcare providers were the 2 areas of lowest satisfaction. Despite previous interventions to improve wait times, it is consistently the lowest ranked item for patient satisfaction. A subset of patients who were followed by a nurse navigator was more satisfied with wait times than those who were not followed by a nurse navigator. Key words: cancer patients, outpatients, patient satisfaction, quality improvement, questionnaires PATIENT SATISFACTION is a core element in the measurement of quality of care at the level of a health system.1 Increasingly, as patient-centered care becomes a focus for hos- pitals, healthcare systems, and government bodies, the measurement of patient satisfac- tion is gaining in importance.1,2 By measuring patient satisfaction, healthcare teams are able to ensure that quality improvement initiatives are pertinent and valued by the patients who are using their services. Because expertise in the measurement of patient satisfaction is de- veloping throughout North America,1 the re- peated and sequential measurement of patient satisfaction over time is becoming recognized as essential to the evaluation of the perfor- Author Affiliations: Segal Cancer Centre (Mss Richard, Parmar and McVey), Jewish General Hospital (Mss Richard, Parmar, Calestagne and McVey), the Hospital Quality Program (Mss Calestagne and McVey); and McGill University (Ms McVey), Montreal, Quebec, Canada. No external funding was received for this project. The authors thank Dr Gerald Batist and Antoinette Ehrler. They also thank Dr Nancy Feeley, Dr Margaret Purden, Abbie Mason, and Mich`ele Lefort for their sup- port in the development of the manuscript. Corresponding Author: Lynne McVey, MSc, RN, Se- gal Cancer Centre, Jewish General Hospital, Pavilion B, Room 103, 3755 Cˆote-Ste-Catherine Rd, Montreal, Quebec, Canada H3T 1E2 (lynne.mcvey@mcgill.ca). mance of a healthcare system. In keeping with this trend, the current patient satisfaction sur- vey was the most recent in a sequence of sev- eral surveys within a comprehensive cancer care center (CCC). Few studies have examined satisfaction with cancer care services.3–5 Variables shown to influence patient satisfaction with can- cer care services include wait times, avail- ability and frequency of contact with health- care providers, and presence of a nurse who is known to the patient.4 Greater under- standing of how to alter the waiting expe- rience and how the presence of a nurse navigator influences satisfaction with cancer care services is needed. This study aimed to add understanding to the measurement of patient satisfaction in a CCC and to pro- vide data to inform quality improvement initiatives that would result in greater satisfac- tion with care for cancer patients. LITERATURE REVIEW Cancer is the leading cause of death in the province of Quebec, Canada.6 Patient advo- cacy has been strengthened since 2002 by the creation of a provincial coalition of concerned citizens who are mobilized to influence the government to improve both the chances of survival and the quality of life of people Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 344
  2. 2. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 Seeking Patient Feedback: Dimension of Quality in Cancer Care 345 living with cancer.7 This coalition has been successful in mobilizing the government to create a publicly funded provincial program to evaluate all cancer care activities within the healthcare system.6 Recent efforts on the part of the government have focused on measur- ing the overall quality of the healthcare sys- tem and aligning improvement work across all healthcare facilities, enabling healthcare lead- ers to acquire data and evaluate the overall performance of the system on core dimen- sions of quality and value. Patient satisfaction Patient satisfaction is identified as a core dimension1 of a proposed model, Whole Sys- tems Measures, currently being piloted at the CCC and evaluated for implementation by the provincial government Ministry of Health and Social Services. Patient satisfaction may be defined as “. . .an individual patient or fam- ily visitor’s subjective perspective on medi- cal services received . . . adopted as one of the indicators of care quality.”8(p122) There is consensus that patient satisfaction is an im- portant outcome that must be evaluated and measured,9 reflecting the shift toward patient- centered care within numerous healthcare associations such as the Conseil Qu´eb´ecois d’agr´ement, Accreditation Canada, the Insti- tute of Medicine, and the public at large.7,10–12 Tracking patient satisfaction along the di- mensions of responsiveness, assurance, empa- thy, and environmental characteristics allows healthcare organizations to conduct qual- ity improvement initiatives with a patient- centered approach.13 Patient satisfaction is recognized as a core element of the mea- surement of quality.1 Incorporating patient satisfaction survey results into care leads to an improved understanding of patient expectations2 and can lead to improved health outcomes,14 such as decreased symp- tom discomfort and better emotional health.15 Evidence demonstrates that patient- centered nursing interventions lead to higher satisfaction rates; therefore, organizations have an ethical obligation to measure patient satisfaction and to act on the results.2 Surveys are vital tools in assessing consumer views, and feedback from patients offer an organiza- tion a direction for improvement.16 There is a need to evaluate patient sat- isfaction with cancer care because of the diversity of patients, complex healthcare needs, and the increased survivorship of this population.17 Key areas have been identified within the context of cancer care that com- monly influence patient satisfaction. These include the demographic characteristics of pa- tients, interpersonal aspects of care, patient- centered care, wait times, continuity of care, and the physical environment.2,3,5,18,19 In the context of cancer care, literature related to patient satisfaction is limited, supporting the need for further investigation into this health- related outcome.3,5 The complexity of physical, psychosocial, and spiritual needs of cancer patients has been addressed by the province of Quebec through the development of the nurse navi- gator role. Nurse navigator interventions fo- cus on patient-centered care, which has been linked to increased patient satisfaction.2 The nurse navigator is meant to guide the patient and the family through the illness trajectory and includes assessment and management of needs and symptoms, patient education, sup- port to patients and their families, and ensur- ing continuity of care.20 Interventions by the nurse navigator are supported by the McGill model of nursing relating to the dimensions of health, the person, their family, and the environment.21 Because of the limited number of studies on patient satisfaction with cancer care, a need exists for further evaluation of patient satisfac- tion with the overall goal of improving satis- faction levels within specific clinical settings. Findings of these studies inform quality im- provement initiatives that may be generaliz- able to other CCCs.22 PATIENT SATISFACTION IN THE CCC Ongoing patient satisfaction surveys have guided the quality improvement initiatives at an urban university teaching hospital in Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  3. 3. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 346 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2010 Montreal, Quebec.4 The CCC at this hospital provides a wide range of services, including chemotherapy treatment, radiotherapy treat- ment, nursing, and psychological services, de- livered by interdisciplinary teams. Surveys oc- cur on an ongoing basis, and in-depth analysis of the survey results is completed regularly for comprehensive review. Several patient satisfaction surveys in the CCC led to similar results. Repeat findings re- garding dissatisfaction with wait times were found despite numerous interventions to ad- dress this problem. Limited resources and high demand for conducting surveys in areas of the hospital outside the CCC forced longer intervals between consecutive surveys than desired. The results of 2 patient satisfaction surveys (2003 and 2005) and a patient focus group (2006) informed the selection of ques- tions in the current survey. The patient satis- faction literature suggests the use of context- specific questions and of questions evaluating patients’ perceptions of safety in healthcare institutions.10,23 It is important to note that be- tween 2003 and 2008, the volume of cancer patients in the CCC increased by more than 35%. Cancer care patients are a vulnerable popu- lation with specific needs. The purpose of this patient satisfaction survey was to add under- standing to the measurement of patient sat- isfaction, evaluate the care provided in the CCC, and understand aspects of care that are priorities for improvement according to pa- tients. The current survey was guided by the following questions: (1) Are cancer patients satisfied with the many aspects of care and ambulatory services provided by the CCC? and (2) How important are the various ser- vices and aspects of care to cancer patients? METHODS A cross-sectional survey design was used; participants were recruited from a CCC re- ceiving more than 3000 ambulatory patient visits within a 1-month period. The inclusion criteria were as follows: registration as an ac- tive patient and/or a family member at the CCC; expressed ability to complete the sur- vey in French or English; and age 16 years or more. Cancer care inpatients, patients who had previously completed the survey during the distribution period, and patients on their first visit to the CCC were excluded from the study. The survey consisted of 21 bilingual vali- dated questions provided in a bank of ques- tions available in Androfact (Agili-T Health Solutions, Inc, St-Laurent, Quebec, Canada). Androfact patient satisfaction software has been used repeatedly within this hospital and throughout Quebec and Canada.24 Content validity of the Androfact bank questions was established by a panel of experts and fur- ther validated by 3600 patients in Quebec, Canada, to ensure relevance, thoroughness, and clarity.24 To maintain consistency, the content of the question bank was not changed significantly. An interdisciplinary team met regularly to select survey items on the basis of previ- ous patient satisfaction surveys, anecdotal ev- idence from clinicians, and Canadian accred- itation requirements. The final item list for the survey included the following: diagnostic tests, interpersonal aspects, safety, informa- tion and education, medication, support, wait and consultation time, and the physical envi- ronment. Five demographic questions asked were as follows: who completed the question- naire (ie, patient or family member), age of patient, gender of patient, knowledge of sup- port programs, and whether the patient had a nurse navigator. Participants rated both their satisfaction and importance levels on each of the 21 items on a 4-point Likert-type scale. Space also was provided to encourage par- ticipants to share additional comments and concerns. The survey was piloted with both English and French patients at the CCC for suitability, relevance to their experience, flu- idity, readability, and timeliness. Volunteers were trained by the Patient Sat- isfaction Program coordinator on how to re- cruit participants for the patient satisfaction survey. Volunteers approached ambulatory CCC patients in the designated waiting areas Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  4. 4. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 Seeking Patient Feedback: Dimension of Quality in Cancer Care 347 and introduced the patient satisfaction survey. Participants had the right to refuse to partici- pate and were told that their anonymity would be preserved and that results of the survey would be used to guide improvements in qual- ity of care and service delivery. By completing and returning the survey, implied consent was assumed. They were given the option of com- pleting surveys on site or returning the sur- veys by mail and were also provided with a contact number that they could call with ad- ditional questions or concerns. This patient satisfaction survey was approved by both the hospital Research Ethics Committee and the McGill University Scientific Review prior to commencement. Statistical analyses were performed using the Androfact 5.2 software. The Likert scale values for both satisfaction and importance were converted to percentage values. Ques- tions not completed by the patient were ex- cluded from the analysis. The percentage val- ues attained for satisfaction and importance were combined to calculate weighted satisfac- tion, also known in the literature as the prior- ity indices.4,23 RESULTS Surveys were distributed to 570 ambula- tory cancer patients between May 12, 2008, and June 13, 2008. The nonprobability con- venience sample consisted of 276 partici- pants (response rate = 48%), with an almost equal representation of men (n = 136, 49.3%) and women (n = 128, 46.4%); 12 individuals chose not to respond to this question. The ma- jority of the participants, 84.1% (n = 232), were between the ages of 45 and 84 years, and approximately 10% (n = 28) of the par- ticipants were between the ages of 18 and 44 years. The majority of the surveys (n = 200, 72.5%) were completed by the patient alone; the remaining surveys were completed with the assistance of a family member. The patient satisfaction survey results were measured against the quality stan- dards published by the local Regional Health Board.25 According to these standards, patient satisfaction rates between 90% and 100% are considered excellent, 80% and 90% accept- able, 65% and 80% passable, 50% and 65% in- sufficient, and less than 50% are considered unacceptable. The Regional Health Board has set 80% as the benchmark for patient sat- isfaction survey results within its participat- ing healthcare facilities,25 which is also the standard utilized by the CCC. When the re- sults of the current patient satisfaction sur- vey were compared with the local Regional Health Board criteria, 11 of the 21 items mea- sured on the survey were within the excel- lent range, 9 of the items were within the ade- quate range, 1 item was considered passable, and no items were defined as insufficient or unacceptable. Overall, responses on the 21-item survey in- dicated that patients were very satisfied. The average patient satisfaction score for men and women was 89.5% and 89.8%, respectively. The average satisfaction score for all the items equalled 89.3% and ranged from 70.9% to 98.7%. The patients were most satisfied with the following items: recommending the hos- pital to family and friends (98.7%), receiving information about when and where to go to have treatments (97.1%), and feeling safe dur- ing care and treatments at the clinic (96.5%). Conversely, items with the lowest weighted satisfaction rates were length of time spent in the waiting room (70.9%) and the ability to contact by telephone someone to answer questions regarding a health problem (79.9%). The most important aspects of care to par- ticipants were as follows: information pro- vided by the team on the results of tests (98.3%), information on why diagnostic tests were necessary (98.2%), and feeling safe dur- ing care and treatments in the clinic (97.9%). However, participants indicated that items re- lating to food availability, length of wait times, and confidentiality in the waiting room as the least important aspects of care within the CCC. The findings of this patient satisfaction sur- vey identified 2 prioritized areas of decreased patient satisfaction and high importance to patients: length of wait times and telephone Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  5. 5. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 348 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2010 contact regarding a health concern. Patients who were followed by a nurse navigator were more satisfied with the length of time spent in the waiting room than those who were not followed by a nurse navigator. There were 103 patients followed by a nurse navigator; 72.5% were satisfied with the length of time spent in the waiting room compared with 66.2% for patients without a nurse navigator (n = 77). DISCUSSION The results of this survey were consistent with other patient satisfaction surveys within the literature26 and within the CCC itself.4 Overall, patients were highly satisfied with the care and services received in the CCC on dimensions including physical environment, diagnostic tests, safety, information and ed- ucation, medication, support, and interper- sonal aspects of care. Interestingly, patients reported similar dissatisfaction levels on wait times and telephone contact with a health- care provider as those on previous surveys in the CCC. The demographic characteris- tics of the respondents were similar to the Canadian cancer population in both age27 and gender.28 Wait times in the CCC Wait times were the area of lowest satisfac- tion at the CCC. This corresponds to previ- ous surveys in the area despite attempts to improve this aspect of the clinic experience. Wait times are recognized as a key access is- sue within the Canadian healthcare system in general; however, for the cancer popula- tion, the problem is more acute.29 Increased survivorship of cancer patients is leading to increased volumes and extended wait times in ambulatory care settings,17 which has also been noted in the CCC. Cancer patients have a unique trajectory of care because they are followed by a pri- mary treating team and supportive and/or palliative care service, and they may require other services because of previous comor- bid conditions. Furthermore, the treatment of cancer requires extensive intervention, often including concomitant chemotherapy, radiotherapy, symptom management, and surgery. This leads to multiple appointments and treatments, which can be burdensome to patients and their families. The literature shows that the waiting expe- rience of cancer patients may lead to varying levels of anxiety, distress, and boredom.17,30,31 Other studies suggest that the experience of anxiety and unoccupied time may lead to the perception of increased wait times.17,31 In ad- dition, throughout the cancer trajectory, most patients have physical discomfort and psycho- logical distress due to numerous symptoms and uncertainty relating to the cancer experi- ence, which may also affect their perception of the waiting experience. As stated, the previous 2 surveys found low patient satisfaction levels with wait times de- spite interventions aimed at improving this as- pect of service delivery. Interventions were focused on system changes to decrease ac- tual wait times as well as perceptual inter- ventions aimed at improving the experience of the wait. Examples included moving to a newly renovated facility with larger waiting rooms, more light, and improved aesthetic ap- peal; the development of an online scheduling system to coordinate appointments and ser- vices; centralizing administrative staff by pro- gram and tumor site to enhance efficiency; and increasing the availability of patient edu- cational materials and support services during the wait time. Unfortunately, despite previous interven- tions aimed at improving the waiting expe- rience and decreasing the length of time spent in the waiting room, patient satisfaction scores remained low on this item in the cur- rent survey. It is hypothesized that dissatisfac- tion with wait times continues because of the increasing volume of cancer patients to the CCC. Between 2003 and 2008, the number of ambulatory clinic visits to the CCC increased by more than 35%. The CCC alongside the Ministry of Health and Social Services is priori- tizing decreasing wait times in the province of Quebec for cancer patients, using the Whole Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  6. 6. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 Seeking Patient Feedback: Dimension of Quality in Cancer Care 349 Systems Measures model. Performance on this indicator will be compared across the CCC and reported to the government for compari- son with other healthcare facilities. Research demonstrates that utilization of Whole Sys- tems Measures in this way leads to improved results for patients.1 Further changes related to the operations of the CCC may lead to measurable improve- ments because system disorganization has been implicated in increasing wait times.17 Another CCC was successful in reducing wait times by 27 minutes through the use of “lean manufacturing principles”focused on increas- ing efficiency, improving outcomes, and min- imizing waste within a system. An example includes making sure that all information on patients is available to the healthcare providers prior to their appointments.32 Implementation of these principles applied simultaneously with Whole Systems Mea- sures has been shown to lead to better results.1 Interestingly, although low satisfaction lev- els with wait times were reported, patients who were linked with a nurse navigator had greater satisfaction levels than those who were not linked to a nurse navigator. This may be related to the patient-centered aspects of the role including support, education, and ad- vocacy, which have been highlighted as im- portant to patients and their families during the experience of waiting.17,19,33 Telephone contact with a healthcare provider in the CCC Another major issue according to patients is the ability to reach someone by telephone who is able to answer questions related to health concerns. The literature supports the use of quality improvement initiatives to en- hance patients’ health information seeking behavior by ensuring patients have multiple sources and appropriate contact information, providing support and accessibility, and link- ing patients and families to resources.34,35 For ambulatory cancer patients, being at home may be anxiety provoking if they are worried about symptoms and complications they cannot manage alone. Having the abil- ity to contact someone by telephone is critical. Nurses in the CCC often provide this link between the hospital and the patient. They advocate for the patient, encourage the patient to come to the hospital in the case of changes of status, and provide support to families. Within the CCC, we have attempted to provide ambulatory patients with support through connections to nurse navigators, pri- mary nurses, and on-call oncologists. De- spite this, one patient commented, “Because of answering machines, in case of emer- gency [it is] very difficult to get to some- one outside [of] working hours.” Although it seems that this current system is not sat- isfactory to all patients, it is not clear ex- actly where it fails. Part of this may be due to the fact that with limited resources not all cancer patients are assigned a nurse navigator. It is important to explore this item further to create appropriate interven- tions. The results of this survey demonstrate further the need to lobby the government for funding for additional nurse navigators to provide the same level of support for all pa- tients and their families. Further investigation comparing satisfaction with care for patients assigned a nurse navigator to those without is warranted. Limitations The current survey had a lower response rate than previous surveys in the area. Little is known about nonrespondents who may not be represented in the current results; there- fore, findings may not be generalizable to the entire patient population of the CCC. CONCLUSION Cancer patients have unique needs; there- fore, measuring their care satisfaction pro- vides valuable information. Although patients have reported high levels of satisfaction on many dimensions of care, lower satisfaction on wait times persists. Nurse navigators mit- igate dissatisfaction with wait times. Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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  8. 8. LWW/JNCQ NCQ200075 August 17, 2010 13:58 Char Count= 0 Seeking Patient Feedback: Dimension of Quality in Cancer Care 351 32. Butcher L. Douglas W. Blayney, MD, on finding new business models to replace the existing ones now threatening medical oncology practices. Oncol Times. 2008;30(13):10-11. 33. Kutash M, Northrop L. Family members’ experiences of the intensive care unit waiting room. J Adv Nurs. 2007;60(4):384-388. 34. Loiselle C, Lambert S, Cooke A. The searching, pro- cessing, and sharing of breast cancer information by women diagnosed with the illness. Can J Nurs Res. 2006;38(3):82-104. 35. Mattioli J, Repinski R, Chappy S. The meaning of hope and social support in patients receiving chemotherapy. Oncol Nurs Forum. 2008;35(5):822- 829. Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.