Focus Groups: An Essential (Not Extraneous!) Tool of Patient-Centered Care

Focus Groups: An Essential (Not Extraneous!) Tool of Patient-Centered Care
By Sara Guastello, Planetree Director of Knowledge Management

Patient-centered quality improvement begins with the voices of patients and families, and relies on the perceptions of these consumers of health care to help identify priorities, drive improvement and evaluate results.  Today, health care organizations have many tools at their disposal to access these paramount perspectives—mail and phone surveys, point-of-service electronic questionnaires, rounding protocols, patient and family advisory councils, discharge phone calls, one-on-one interviews, mystery shopper initiatives and patient shadowing, to name just a few.

Given this expansive array of methodologies for amplifying the voices of patients, have focus groups become obsolete?  Hardly, says Planetree!  On the contrary, focus groups remain a vital component of any health care establishment’s efforts to achieve a greater understanding of the experiences, attitudes and behaviors of their patients, employees and community-at-large.  That is why Planetree has emphatically and continuously relied on focus groups to anchor its model for patient-centered quality in the lived experiences of those on the front-lines of health care.[1] We conduct approximately 200 patient focus groups every year, annually accessing the perspectives of nearly 1500 patients and family members, and using their insights to drive patient-centered quality improvement through involvement in policy efforts, research and advocacy.[2] Rooted in their voices, the Planetree methodology has remained relevant and responsive for more than three decades, even in the face of tremendous changes in the global health care marketplace.

At a more micro-level, focus groups remain Planetree’s foremost instrument for supporting individual organizations in crafting a site-specific patient-centered care implementation plan.  Wherever an organization is along the pathway to patient-centered care—be it discovering the most powerful levers for change, activating caregivers to problem solve and create change, advancing continuous quality improvement or innovating to raise the bar—the linchpin for this work is focus groups.

What is a focus group?

A focus groups is a form of qualitative research, defined as a “carefully planned discussion designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment.”[3]  Researchers[4] have identified the following core elements of a focus group:

  • The group is composed of individuals whose points of view are requested to address a single topic.
  • The group is small, 6-12 members, and is relatively homogeneous.
  • The group discussion is facilitated by a trained moderator with prepared questions and probes designed to induce participants’ responses.
  • The goal is to elicit the perceptions, feelings, attitudes, and ideas of participants about a selected topic.
  • Focus groups do not generate quantitative information that can be projected to a larger population.

Structured as such, focus groups create an unparalleled opportunity to probe health care consumers’ experiences and perceptions in depth and in their own words, and to examine not only what they think, but why they think the way they do.

Power in Numbers

The group dynamic powers this formidable feedback methodology exponentially.  Trained facilitators capitalize on the group interaction to “reveal dimensions of understanding that often remain untapped by more conventional data collection techniques.”[5]  Participants are able to build on one another’s statements, react to others’ comments, pose clarifying questions, corroborate shared experiences and/or add divergent points of view. Indeed, the goal of a focus group is not to reach consensus among participants, but rather to deepen understanding of the question(s) at hand by eliciting a range of responses.

Unlike solitary patient feedback enterprises (e.g. surveys, one-on-one interviews, etc.) the communal aspect makes participating in focus groups a social and enjoyable experience (especially when the group is held over a tasty meal).  In fact, it is not at all uncommon for patients and family members who participate in Planetree focus groups to make a point of thanking the facilitator for the opportunity to share their stories and connect with others in their community.

Participant-Driven Feedback

Though the moderator is equipped with a prepared set of carefully constructed open-ended questions to elicit information on the particular topics of interest, the exchanges and interactions between group members are truly what guide the discussion. The interplay between participants can be enormously illuminating about what is most top-of-mind and what triggers the most heated and emotional discussions.  It can help us to move from asking about what we think is most important to patients to instead delving in more depth into their impressions and ideas about what they identify as most important.

Giving Voice to Those We Don’t Often Hear

When it comes to acquiring knowledge on patients’ perceptions of care and their health care experiences, accessing the perspectives of highly engaged patients does not present much of a challenge.  As already-engaged patients, they have embraced their role as our partner and guide in improving health care. The challenge arises in extending those activities to reach the most reticent, reluctant and disenfranchised patients, for instance those with low literacy and those who may opt out of voluntary surveys or service on patient advisory councils because they feel their opinions and perspectives are irrelevant or inconsequential.  By providing the opportunity for them to be a part of a non-threatening small group discussion, focus groups promote understanding of a more diverse and balanced set of viewpoints, effectively giving voice to those who those who are reluctant to speak up.

Voice of the Patient: A Comprehensive Approach

While there are many reasons to use the focus group methodology to gain valuable insight into patients’ perceptions of their health care experiences, there are times when focus groups are not the preferred approach for capturing this information. Focus Groups 101 Focus groups are but one component of a comprehensive strategy for accessing the perspectives of patients.  They can be an invaluable complement to other tactics, including surveys, point-of-service rounding and patient and family advisory councils; but even the most robust focus group strategy should not be undertaken as a replacement for these other approaches.

Timing is Everything

In constructing this multi-method approach, it is important to consider how patients’ viewpoints—or perhaps more relevant, their willingness to share their candid viewpoints—may be influenced by how “fresh” their care experience is.   For many health care organizations, point-of-care rounding or surveying techniques are extolled for the real-time data they produce, as well as the opportunities they afford for immediate service recovery or self-correction if the need is uncovered.

Focus groups are generally held with discharged patients who are reflecting on past care episodes.  As such, they are not intended to provide actionable real-time information.  However, the time lapse provides participants some distance from their encounters that may enable them to provide a richer and more contemplative accounting of their experience in its entirety.  In addition, studies demonstrate that the fear of being labeled a “difficult patient” coupled with the fear of retribution should they express dissatisfaction, are barriers to patients speaking up candidly about a specific health care episode while they are still in the midst of it.[6],[7]  In this case, the post-discharge focus group is a forum where patients can share unguarded comments of all types, positive and negative, without fear of retribution.

But I’ve Already Surveyed My Patients

Patient experience surveys are a tremendously constructive tool for capturing quantitative data to inform improvement efforts.  This quantitative data can be used to benchmark performance against peers and to measure progress over time.  By design, surveys reach a more expansive pool of respondents than focus groups and often can generate useful information on a wide array of topics.  Perhaps, though, you have been in the position of reviewing survey results only to find that the data leave you with more questions than answers, as you endeavor to make sense of conflicting conclusions or to understand the context for the responses.  In the words of one CEO of a Planetree Designated Patient-Centered Hospital®, “You wouldn’t survey your spouse or your children to find out how the relationship is working; you would talk to them.  We need to reach out, pay attention, and listen.”

What’s more, by drilling down the responses to percentiles and top box scores, surveys run the risk of de-humanizing the people who complete the survey.  When conducted in tandem with regular patient experience surveys, focus groups can uncover the stories behind the numbers.  They can provide the clarification, context and meaning that may feel lacking in traditional surveys.

Conclusion

Understanding the benefits and drawbacks of these various voice of the patient methodologies further establishes the importance of a multi-method approach. Indeed, that is why Planetree’s Patient-Centered Hospital Designation Program® includes criteria that address a range of approaches for promoting meaningful dialogue with patients, families and the community, including[8]:

  • Use of patient and family advisors
  • Routine focus groups (at a minimum, every 18 months)
  • An effective process to encourage patients and families to communicate with staff any concerns related to their care
  • Independently administered patient experience surveys.

Increasingly, health care quality mandates around the world underscore the importance of listening to the patient voice and partnering with patients and families as the consumers of health care services.  Focus groups provide an opportunity to do just that.

Of course, holding a focus group is only the first step in truly engaging patients and families as our partners in transforming how care is delivered.  Even the most lively and constructive focus group is in vain if the information gathered is not made actionable. Beyond using the patient stories, recommendations and ideas as the basis for planning and improvement efforts, the comments derived from focus groups can be immensely poignant and powerful motivators for staff, underscoring in patients’ own words what matters most to them, what it meant and how it felt when staff met their needs, and how it felt when care did not meet their expectations.

Focus groups moderated by Planetree’s experienced team of facilitators are the centerpiece of all Planetree assessments.  Drawing on the focus group findings, a common understanding of your organization’s present state, goals and desired outcomes will be established.  The information is then used to generate a blueprint for your organization’s culture change effort.  To schedule or learn more about Planetree’s assessment offerings, contact contact Jim Kinsey, Planetree’s Director of Member Experience, at 203-732-1362 or jkinsey@planetree.org.

 


[1] Frampton SB, Charmel PA and Guastello S editors. The Putting Patients First Field Guide: Global Lessons in Designing and Implementing Patient-Centered Care. San Francisco: Jossey-Bass, 2013.

[2] Frampton SB, Guastello S. and Lepore M. “Compassion as the foundation of patient-centered care. The importance of patients experiencing compassion in action.” Journal of Comparative Effectiveness Research, 2013, 2(5): 443-455

[3] Krueger RA. Focus groups. A practical guide for applied research (2nd ed.). London: Sage, 1994.

[4] Vaughn S, Schumm JS and Sinagub J. Focus group interviews in education and psychology. London: Sage, 1996.

[5] Kitzinger J. “Qualitative research. Introducing focus groups.” BMJ. 1995 Jul 29; 311(7000):299-302.

[6] Frosch DL, May SG, Rendle KAS, Tietbohl C and Elwyn G. “Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making,” Health Affairs, 2012, 31(5):1030-1038.

[7] Planetree, Inc., and Picker Institute. Patient-Centered Care Improvement Guide. Derby, CT, and Camden, ME: Planetree, Inc., and Picker Institute, 2008

[8] Planetree, Inc. Planetree Designation Process Manual, Derby, CT, 2011.