Client Satisfaction Evaluations

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WHO/MSD/MSB 00.2gWorkbook 6ClientSatisfactionEvaluationsWorkbook 6 · Clent Satisfaction Evaluations1

WHO/MSD/MSB 00.2gcWorld Health Organization, 2000WHOWorld Health OrganizationUNDCPUnited Nations International Drug Control ProgrammeEMCDDAEuropean Monitoring Center on Drugs and Drug AddictionThis document is not a formal publication of the World Health Organization (WHO) and all rights are reserved by theOrganization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or inwhole but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents bynamed authors are solely the responsibility of those authors.2Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gAcknowledgementsThe World Health Organizationgratefully acknowledges the contributions of the numerous individualsinvolved in the preparation of thisworkbook series, including the experts who provided useful comments throughout its preparation forthe Substance Abuse Department,directed by Dr. Mary Jansen. Financial assistance was provided byUNDCP/EMCDDA/Swiss FederalOffice of Public Health. Cam Wild(Canada) wrote the original text forthis workbook and Brian RushWorkbook 6 · Clent Satisfaction Evaluations(Canada) edited the workbook series in earlier stages. JoAnne EppingJordan (Switzerland) wrote furthertext modifications and edited theworkbook series in later stages.Munira Lalji (WHO, SubstanceAbuse Department) and JenniferHillebrand (WHO, Substance AbuseDepartment) also edited the workbook series in later stages. MaristelaMonteiro (WHO, Substance AbuseDepartment) provided editorial inputthroughout the development of thisworkbook.3

WHO/MSD/MSB 00.2g4Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gTable of contentsOverview of workbook series6What is a client satisfaction evaluation?7Why do a client satisfaction evaluation?7How to do a client satisfaction evaluation?8Conclusion and practical recomendation17Comments about case examples19Case examples of client satisfaction evaluationPart A: An evaluation of satisfaction with a statedrinker driver treatment program21Part B: Client satisfaction with residential substancetreatment programmes26Part C: The case of community methadonstreatment programs32Workbook 6 · Clent Satisfaction Evaluations5

WHO/MSD/MSB 00.2gOverview ofworkbook seriesThis workbook is part of a series intended to educate programme planners, managers, staff and other decision-makers about the evaluation ofservices and systems for the treatmentof psychoactive substance use disorders. The objective of the series is toenhance their capacity for carrying outevaluation activities. The broader goalof the workbooks is to enhance treatment efficiency and cost-effectivenessusing the information that comes fromthese evaluation activities.This workbook discusses the assessment of client satisfaction. It focuseson:reasons for assessing client satisfactionlthe use of client satisfaction measures for programme improvementllmeasures of client satisfactionIntroductory WorkbookFramework WorkbookFoundation WorkbooksWorkbook 1: Planning EvaluationsWorkbook 2: Implementing EvaluationsSpecialised WorkbooksWorkbook 3: Needs Assessment EvaluationsWorkbook 4: Process EvaluationsWorkbook 5: Cost EvaluationsWorkbook 6: Client Satisfaction EvaluationsWorkbook 7: Outcome EvaluationsWorkbook 8: Economic Evaluations6Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gWhat is a clientsatisfaction evaluation?Client satisfaction evaluations arean excellent opportunity to involveclients or patients in the process ofevaluating your programme.Client satisfaction evaluations can address1 . the reliability of services, or the assurance that services are provided in aconsistent and dependable manner;2 . the responsiveness of services or thewillingness of providers to meet clients/customer needs;lwaiting times for service componentslfrequency of appointmentsltime spent with counsellorlthe ‘humanness’ of servicesthe effectiveness of services in ameliorating their problemsl3 . the courtesy of providers; and4 . the security of services, including thesecurity of records.Specific questions may assess clients’views about :lthe physical setting of serviceslthe helpfulness of support stafflinformation resourceslthe competence of counsellorslthe costs of servicelthe relevance of services to their needslthe accessibility of servicesWorkbook 6 · Clent Satisfaction EvaluationsClient satisfaction occupies an ‘intermediate’ step in establishing a healthy culture for evaluation within a programmeor a setting. It often follows processevaluation and cost analysis, and precedes outcome and economic evaluations. Accordingly, measures of clientsatisfaction lie somewhere between ‘process’ and ‘outcome’ measures. When theconcern is with the extent to which clients are satisfied with the context, processes, and perhaps the costs of a treatment service or network, the relevantmeasures of satisfaction can be viewedas process measures. However, when theconcern is with the extent to which clients view the programme as having beenhelpful in resolving their problems, client satisfaction becomes a proxy outcome measure.7

WHO/MSD/MSB 00.2gIt is worthkeeping inmind thatsatisfactionwith thetreatmentprocesses,treatmentcompliance,and positivetreatmentoutcomes areinter-related.Client satisfaction with treatment processes may both influence, and be influenced by, treatment outcomes. Clientswho are not satisfied with a service mayhave worse outcomes than others becausethey miss more appointments, leaveagainst advice or fail to follow throughon treatment plans. On the other hand,clients who do not do well after treatmentmay have less than favourable attitudestowards a treatment service, even if it wasof high quality by other criteria. In practice, these mutual influences may be difficult to disentangle. It is worth keepingClientsatisfactionsurveys mayprovide theonly means forclients toexpressconcernsabout theservicesreceived. Why do a clientsatisfaction evaluation? . evidence ofpositive clientsatisfaction isnot, in itself,sufficient toestablish theeffectiveness oftreatment. 8The assessment of client satisfaction addsan important ‘consumer’perspective toevaluations of PSU treatment services andsystems. Client satisfaction evaluationscan be viewed as an opportunity to‘consult’with clients about their experiences in your programme. Client satisfaction surveys may provide the only meansfor clients to express concerns about theservices received, and to express theirviews about new services that are needed.Client satisfaction ratings have beencriticised as indicators of the quality ofhuman services because they may reflectunrealistic expectations. While this criticism may be valid in some instances, re-in mind that satisfaction with the treatment processes, treatment compliance,and positive treatment outcomes are inter-related.Ratings of different dimensions of satisfaction have been highly correlated insome studies, and scores on these dimensions have been added to yield overallsatisfaction ratings. However, responsesto specific items are of interest to service providers who want to find out howa particular aspect of the service couldbe improved.search with clients of mental health services suggests that they can effectivelydiscriminate between services that aredifferent in quality (Lebour, 1983;Sheppard, 1993). It is, however, important to recognise that evidence of positive client satisfaction is not, in itself,sufficient to establish the effectivenessor accessibility of treatment. Clients withno base for comparison may be satisfiedwith services that are ‘ineffective’as determined by more objective outcomeevaluations. On the other hand, clientsmay be displeased with services thatachieve the objective of reducing theirPSU but employ rigid or authoritarianapproaches.Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gHow to do a clientsatisfaction evaluation?The most common method for assessingclient satisfaction is with self-administered questionnaires. These may be givento clients as they enter or leave services,or at various times in between. They canalso be administered at some point aftertreatment has been completed, when theoutcomes of treatment are more clear tothe client. Client satisfaction questionnaires can be completed at the time theyare distributed, or at a later date selectedby the client or program personnel.Stamped, return envelopes can be provided if questionnaires are to be returnedby mail. Satisfaction questionnaires alsocan be mailed to former clients withstamped, return envelopes. A cover lettershould explain why the questions are being asked and how the information willbe used. The cover letter should also indicate if individual replies will be considered confidential or anonymous, and whatsteps will be taken to ensure that this isthe case. For ethical reasons, risks to clients should be made clear. It should bestated that their responses will not in anyway affect present or future treatment.Programme managers typically want thequestionnaire to identify the respondentso that they can follow-up with these individuals who express concerns about theservices received. If this is the case, clearprovisions for confidentiality must bemade, including, for example, removal ofthe information identifying the client priorto data analysis by computer or other tabular means. For more information aboutthese ethical issues, see Workbook 2 ofthis series, Step 1A, entitled ‘ManageEthical Issues.’Client satisfaction also can be assessedin face-to-face or telephone interviewsor focus groups. These strategies aremore expensive than self-completedquestionnaires. If interviews or focusgroups are used, it is preferable to havethem conducted by someone who is notconnected directly with the service. Thismay be an independent evaluator, volunteers or former clients themselvestrained to take on this role. If interviewsor focus groups must be done by a manager or staff member, it is best not to havethe individual’s principal therapist askabout client satisfaction because clientsmay be reluctant to comment negativelyabout their treatment directly to theirtherapist. Interviews may be highlystructured, perhaps guiding the clientthrough the same type of questionnaireused on a self-administered basis in othersituations. Other interviews, and certainly focus groups, will be much lessstructured and the resulting informationwill be analysed qualitatively. Workbook1 provides guidance for conducting focus group and semi-structured/unstructured interviews. Workbook 2 offers advice on analysing the resultinginformation.The design and conduct of client satisfaction surveysClient satisfaction surveys are most useful when they are designed to meet specific objectives and when they use appropriate methods and measures. ThisWorkbook 6 · Clent Satisfaction Evaluationsinvolves choices of sampling procedures,timing, cultural acceptability, and sensitivity of the questions to various levels ofsatisfaction.9

WHO/MSD/MSB 00.2gChoosing samples of clientsThere are noright or wrongways to choosesamples in clientsatisfactionsurveys.However, it isimportant thatyour sample beconsistent withthe evaluationobjectives.Your strategy for selecting clients for a satisfaction survey can influence the kinds of results you obtain. If the surveys are limited toclients who complete treatment, the resultswill probably differ from those obtained insurveys that include people who havedropped out of the programme. There areno right or wrong ways to choose samples inclient satisfaction surveys. However, it is important that your sample be consistent withthe evaluation objectives. If the objective isto learn about client satisfaction among thosewho complete treatment then there will beno need to involve treatment drop-outs.However, if the aim is to find how, in general, clients feel about the programme, a rep-resentative sample of all clients completingthe intake process would be more appropriate. Regardless of the sample chosen, youmust be sure to clearly describe the samplein subsequent reports. Limitations to thegeneralizability of results must be stated. Forexample, are your results biased due to theexclusion of early drop outs?Once you have decided which types of clients will be involved in satisfaction surveys,you have a number of options for choosingparticular clients, including a random or systematic sample. These and other options forsampling are discussed in Workbook 2.Choosing samples of clientsThere is no best timing forthese surveays,except to ensureconsistency withthe objectives ofthe evaluation.The timing of client satisfaction surveyscan influence your results. Clients withpositive views during or immediately following treatment may change their mindsif they later relapse. On the other hand, clients may gain a greater appreciation of services as their value becomes evident in anincreasing number of real life situations.There is no ‘best’ timing for these surveys,except to ensure consistency with the objectives of the evaluation. If the objectiveis to find out what clients feel at the timeof discharge, then ask clients to completea satisfaction questionnaire as they areabout to leave. However, if the aim is tofind out if clients are satisfied as part of anoutcome evaluation, wait until some period of time has passed before askingformer clients to complete a satisfactionquestionnaire. The timing of surveysshould be clearly indicated in reports andany associated biases should be discussed.If, for example, clients complete satisfaction questionnaires following an emotional‘graduation’ ceremony this could bias attitudes in favour of the programme.Culture sensituvityCultures differ with respect to expectations of feedback on public and privateservices. In jurisdictions where ‘consumerism’ is firmly established, frank verbalor written feedback may be freely given.However, direct negative feedback insome cultures may be considered impolite and complaints may only be sharedwith intimate acquaintances. Direct andchallenging questions also may be cultur10ally inappropriate (NIDA, 1993). Experiences with (and attitudes toward) the useof questionnaires, interviews, focusgroups and other methods of inquiry alsodiffer between cultures. Methods for soliciting client feedback must take intoaccount the prevailing cultural norms andseek to ensure the use of appropriatemethods that assess client beliefs andopinions.Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gMeasures validated in one culture maynot be appropriate in others. Simpletranslation of questionnaire items doesnot guarantee that the items will havethe same meaning across cultures(Attkisson and Greenfield, 1994). Considerable effort may be required to generate new, culturally appropriate questions. Clients, or people advocating ontheir behalf, should be involved in thisprocess of questionnaire design to en-sure that the measures will provide a validindication of client satisfaction.Some groups of clients may also find particular methods for assessing client satisfactionmore acceptable than others. For example,those with poor cognitive or reading skills mayprefer personal interviews over a written questionnaire. However, clients who are shy orhave low self-esteem may prefer questionnaires over interviews.Sensitivity to different levels of satisfaction.if satisfactionis rated on afive-point scale,the proportionsof clients whoare verysatisfied , somewhatsatisfied or neutral can bebetterdiscriminated.Many satisfaction surveys of clients ofhealth and social services have shownhigh levels of satisfaction partly becausethey have used insensitive measures(Ruggeri, 1994). An example would beusing questionnaire items that only havetwo response options (satisfied/not satisfied). Such items tend to invite a ‘satis-fied’ response, even from those who areneutral of even mildly dissatisfied. However, if satisfaction is rated on a five-pointscale, the proportions of clients who are‘very satisfied’, ‘somewhat satisfied’ or‘neutral’ can be better discriminated, ascan the proportions who are ‘somewhat’or ‘very’ unsatisfied .Seeking out expressions of dissatisfactionClients . mayfeel especiallyobliged to showthat they aregrateful andsatisfied with theservicesprovided.Clients of human service agencies have atendency to be grateful for the attention theyreceive, and to be reluctant to criticise inthe event that this leads to negative consequences. Clients with low self-esteem, orwho are conscious of status differencesbetween themselves and service providers,may feel especially obliged to show thatthey are grateful and satisfied with the services provided. These tendencies can beovercome if clients are assured that theirhonest feedback is being sought and thatthere will be no consequences for those whocriticise the services in question. This canbe made clear in verbal or written instructions for completing satisfaction questionnaires or participating in interviews or focus groups. Confidentiality of the resultsWorkbook 6 · Clent Satisfaction Evaluationsshould be assured as strongly as possible.It is desirable to actively seek out sourcesof discontentment by asking the followingkinds of questions:lAre there any parts of the programmethat you liked more than others?lHave you any suggestions for ways inwhich the programme can be improved?Also, look for behavioural indicators ofdissatisfaction, for example, high drop-outor no-show rates within specificprogrammes, or for specific counsellors.While many factors may contribute to lowparticipation, low client satisfaction maybe involved.11

WHO/MSD/MSB 00.2gEstablished questionnaires for assessing client satisfactionWhen choosing a questionnaire for yourevaluation, you first need to considerwhether all dimensions of client satisfaction are relevant to the service components being evaluated. It is often thecase that one treatment agency providesdifferent types of services and activities.You will have to decide whether yourclient satisfaction questionnaire willprovide feedback about individual service components, or whether you willfocus on a more global level ofprogramme participation. This will bean issue to resolve in the assessment ofsatisfaction with services receivedacross a large network of agencies. Ifthe intention is to use the resulting information to suggest highly specific areas for service or system enhancement,you may need to customise your selection of client satisfaction measures to fitparticular service or system components. This may ultimately involve achoice between a standardised, globalmeasure of satisfaction available frompublished literature (see below), andquestionnaires tailored to your specificinformation needs.If you are going to use a structured, selfadministered questionnaire, you may select one from the published literature.Such measures in the public domain willlikely have data available on reliabilityand validity in a particular setting. Thisis a big advantage, but must be considered in light of cultural variations between the culture in which the questionnaire was validated and the culture inwhich you intend to use it now . In addition, standardised questionnaires may betoo general to give you the kind of detailed feedback you need for making improvements to specific parts of the program. Feedback unique to your programcan be derived from a specially-tailoredquestionnaire, although issues of reliability and validity will be of concern. Open12ended questions can also be added to aself- administered questionnaire and thenanalysed qualitatively.A questionnaire which can be used to assess client satisfaction is the Client Satisfaction Questionnaire (CSQ-8). This is awidely used instrument with publisheddata on reliability and validity (Greenfieldand Attkisson, 1989). The instrument isavailable in several languages, includingEnglish, Spanish, Dutch and French (deBrey, 1983; Roberts et al., 1984; Sabourinet al., 1987). Case examples of evaluations that used the CSQ-8 also are reported at the end of this workbook.Workbook 1, Appendix 2 also contains fourother examples of questionnaires that canbe used to assess client satisfaction. Thereare no data on the reliability and validity ofthese other instruments. However, they maybe helpful in your situation or stimulate ideasfor the development of a questionnaireunique to your needs.A report from the National Institute onDrug Abuse (1993) entitled ‘How Goodis Your Drug Abuse TreatmentProgram?’contains a series of client satisfaction questions used in an AIDS RiskReduction Project. Two other measures ofclient satisfaction appropriate for PSU services are the Service Satisfaction Scale(SSS-30) (Attkisson and Greenfield,1984), and the Verona Service Satisfaction Scale (VSSS) (Tansella, 1991). TheSSS-30 is a 30-item multi-dimensionalscale developed on the basis of experiencewith the Client Satisfaction Scale. The firstcase example at the end of this workbook(Part A: by Thomas Greenfield) describesthe SSS-30 in greater detail. The VSSS isan 82-item scale which covers seven dimensions — overall satisfaction, professional skills and behaviours, information,access, efficacy of interventions and relative improvement.Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2gDeveloping your own client satisfaction questionnairesA good starting place for the development of a new client satisfaction questionnaire that is tailored to your individual service or treatment system willbe your programme logic model and accompanying written descriptions ofyour programme (see Workbook 1).These will identify the main components, activities and treatment processesfor which client satisfaction ratingscould be developed. In addition, clientscould be asked to rate their satisfactionwith the staff, comprehensiveness of theservices provided and aspects of thephysical environment. It would also beuseful to convene small groups of current and former clients to explore issues most relevant to their needs. Thesegroups may be helpful in testing ideasfor questionnaire items and responseoptions. The instruments contained inWorkbook 1, Appendix 2 also will beuseful.To help validate measures of client satisfaction, the ratings can be compared withverbal reports or satisfaction ratings fromfamily members or others that are familiarwith the services received. You can alsocompare the results using your new questionnaire with the results of an instrumentlike the CSQ-8 completed by the samepeople. Client satisfaction ratings can alsobe compared with actual behaviours thatsignify satisfaction with services. Comparisons could be made, for example, between client satisfaction ratings and theirrecord of keeping appointments, completing treatment, or returning for further treatment following a relapse.Using client satisfaction measures during times of change inservice deliveryOnce reliable client satisfaction measures are available, they can be usedfor routine or periodic ‘check-ups’ onthe quality of services from the clients’perspective. They also can be used toassess client reactions to changes inservice delivery being implemented.[Clients] couldbe asked if theyfeel satisfiedwith theinformation thatis available onthe range ofservices in thecommunity.For example, changes may be plannedto increase the efficiency of a servicebut there are concerns that these couldlead to decreased client satisfaction.Measures of satisfaction taken before orafter the changes are introduced willshow if this has been the case.Measuring client satisfaction in evaluations across two ormore agenciesIt is possible to assess client satisfactionwith services received across a networkof programmes, rather than focusing onthe client’s experience with only one service provider. Not all clients will haveexperience with other services in thetreatment network. However, clients ofall services may have useful perspectiveson system-wide issues. For example,Workbook 6 · Clent Satisfaction Evaluationsthey could be asked if they feel satisfiedwith the information that is available on therange of services in the community. Theycould also be asked to rate their satisfaction with recommendations for referralgiven the options that were presented. Didthey like this referral? Was it too far awayfor them? Do they feel satisfied with beingreferred to a residential service when they13

WHO/MSD/MSB 00.2gmight have gone to a day treatment or outpatient service (and vice versa)? A reviewof a logic model for the treatment systemmay suggest other topics to be included inclient satisfaction surveys. For example,waiting times for moving from one service component to another may be of particular concern. The issue of duplicationof services is also important to explore,for example, whether agencies in the system duplicate the collection of assessmentinformation when the client moves fromone service to another.Clients who have experienced two or moreservices in a network may have valuableperspectives on the degree to which theseservices are co-ordinated. Sample ques-tions concerning client satisfaction withinter-service co-ordination are:lHow satisfied are you with the way that(name of both services) exchangedtreatment information about your problems?lHow satisfied are you with the information that (name of both services) provided to you about each other’s treatment programmes?lHow satisfied are you with the waysthe treatment staff of (name of both services) worked together to help you withyour problems?lBased on your experience, how well do(name of both services) work together?It s your turnPut the information from this workbookto use for your own organisation or treatment network. Complete these exercisesbelow.Remember to use the information fromWorkbooks 1 and 2 to help you completean evaluation plan. Review that information now, if you have not already done so.Exercise 1Exercise 2Think about your treatment programmeor local treatment network. List five general areas in which you want to know theviews of clients or patients.Using the information provided in thisworkbook about how to design and conduct a client satisfaction evaluation, makethe following decisions:Example:lDecide what modality you will use tocollect the data (questionnaires, interviews, focus groups)lChoose a sampling procedure forchoosing clients to surveylDecide the timing of the evaluationWhat do clients think about the helpfulness of our clinicians?1)2)3)4)5)14Evaluation of Psychoactive Substance Use Disorder Treatment

WHO/MSD/MSB 00.2glDevelop a procedure for ensuring clients’ confidentiality and promotingtheir honesty in answering questionslDecide who will help you administer thequestionnaires/interviews/focus groups.‘Please help us improve our programme by answering some questions aboutthe services you have received. We areinterested in your honest opinion,whether it is positive or negative. Toensure your confidentiality, please donot write your name on this form.When you are finished, place the formin the envelope (provided) and seal itclosed, then place it in the collectionbox in the waiting area.’Example (from above):lData will be collected using a self-report questionnaire.lAll clients checking in for appointments during the week of December10th will be handed the survey to complete while waiting for their appointments.lData will be collected over a one weekperiod of time only, from 10-15 December.lClients will be given envelopes inwhich to place their completed questionnaires before returning them to thecollection box. The following statement will appear at the top of the questionnaire:lBecause the questionnaire assesses client satisfaction with staff, it is not feasible for staff to be involved with distributing or collecting questionnaires.A outside research assistant will behired to hand out the introductory letters, consent forms, and questionnaires.The assistant also will remove the questionnaires from the collection box andkeep them in a safe place to ensure theirconfidentiality from the staff.Now it’s your turn. Follow the same procedure for your evaluation questions.Exercise 3You will need to prepare an introductoryletter and consent form that explains thepurpose of your study. Review Section 1Aof Workbook 2, entitled Manage Ethical Issues, for more information about theimportant topic of participants’ rights inevaluation research.ldescribes the purpose and methods ofthe studylexplains what they will need to do ifthey participatelexplains that participation is voluntaryIn general, all participants should be askedpermission ahead of time before beingenrolled in the study. When you do this,your should explain the purpose, nature,and time involved in their participation.No person should be forced or coerced toparticipate in the study.Note that an ethical committee maywaive the requirement of a signed consent form if the research contains minimal risk. In these cases, researchers stillneed to provide full information to participants. A consent form is included inthe following example for the sake ofcompleteness.A standard practice is to have each participant sign a consent form, which:Workbook 6 · Clent Satisfaction EvaluationsExample (from above):15

WHO/MSD/MSB 00.2gIntroductory Letter:We are asking your help in improving ourprogramme by filling out a 2 page questionnaire about the services you have received here. The questions will ask aboutyour views regarding our staff members.They will take about 10 minutes to complete. All information that you provideus will remain strictly private and confidential.If you agree to participate, please read andsign the consent form (attached) and return it to the research assistant who gaveyou this packet when y

Workbook 6 Clent Satisfaction Evaluations 7 WHO/MSD/MSB 00.2g What is a client satisfaction evaluation? Client satisfaction evaluations are an excellent opportunity to involve clients or patients in the process of evaluating your programme. Client satisfaction evaluations can address 1. the reliability of services, or the assur-

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