Up until 1993 New Zealand provided healthcare services through its 14 Area Health Boards (AHBs). In 1993 the 14 Area Health Boards were replaced by 23 Crown Health Enterprises (CHEs) structured as “for-profit” organizations. The funding of health services was coordinated by four Regional Health Authorities (RHAs) and a separate public health purchasing agency, the Public Health Commission. This allowed the purchasing of health services to be separated from the provision of health services.
In 1997 the National-New Zealand First Coalition Government again transformed the structure of the health system. The four AHBs were combined into one national purchasing agency, the Health Funding Authority (HFA) and the 23 CHEs were reconfigured as 24 not-for-profit Crown-owned companies and renamed Hospital and Health Services (HHSs).
During 2001-2002, the Labour-Alliance Coalition Government yet again changed the structure of the health system: Its health policy “Focus on Patients” required the establishment of 21 District Health Boards (DHBs) and a large number of Primary Health Organisations (PHOs) to manage primary care, including general practitioners and their support services.
The emphasis on financial viability was replaced by the use of a Balanced Scorecard approach, in which the financial aspect was complimented with other operational performance measures. Most importantly, the new government health policy emphasised that health service providers who could demonstrate an improvement in patient focus would be encouraged.
During these early days, patient satisfaction was monitored on an ongoing, quarterly basis. The rationale for this was that it would provide the then Department of Health with a performance indicator that, unlike other more traditional measures, was based on the patients’ perspective. To assist them with this task, the Department of Health provided a few pages of instruction that outlined the methodology to be followed.
The CHEs implemented this patient survey which had been developed on the basis of what was available at the time in the USA. It was a rather basic tool and the results were accordingly very suspect. Moreover, there was little consistency between the CHEs on how they implemented the survey: some handed the forms out on discharge, others used a postal version. The department within the Ministry of Health which was charged monitoring performance was known as the Crown Health Enterprises Monitoring Unit (CHEMU).
Over the next 7 years or so, all public hospitals monitored (often in their own fashion) their inpatients’ satisfaction with the care they received from their hospitals. At the end of each quarter, they would calculate the average of the “very good” scores on each of the 26 items on which service delivery was measured and then submit an average of these averages to the Ministry.
Each quarter, the renamed Crown Company Monitoring and Advisory Unit (CCMAU) would produce a “league table” that showed how each Area Health Board compared with another in terms of this average percentage “very good”. Although some hospitals at the top of the list would have regarded that comparison as useful, and perhaps as a validation of their business or organisational strategy, others, in particular those whose resulting satisfaction rates tended to be relatively lower in rankings, often questioned its accuracy and validity.
Over time, it became obvious that the patient satisfaction survey suffered from quite a few methodological shortcomings: the questionnaire was found to be wanting, the prescribed methodology was not detailed sufficiently to allow consistent implementation and consequently the scientific validity and reliability of the results left a lot to be desired.
Congruent with our own misgivings, which were expressed in the local medical press in 1999 (see Zwier and Clarke 1999), CCMAU convened a working party consisting mostly of hospital quality managers that set itself the task to write the guidelines for a new Patient Satisfaction Survey.
The survey had to be statistically robust, have a greater focus on specific aspects of care and include both inpatients and outpatients. By standardising the survey methodology, and requiring DHBs to comply with the prescribed process, it was hoped that it would provide CCMAU with the ability to provide Ministers and DHBs alike with a balanced comparative analysis of patient satisfaction over time, and between DHBs.
The 100-page report which this group produced in June 2000 (see Patient Survey Guidelines 2000) outlined in great detail the methodology that all District Health Boards (DHBs) now are asked to implement so that they can correctly monitor patient satisfaction among their inpatient and outpatient populations.