Patient satisfaction surveys
Consensus has been made around the importance to assess perceptions and expectations of patients about health care services. In fact, patient satisfaction is pointed out as an important clinical indicator for evaluating service quality [I]. Nevertheless, patient satisfaction surveys must be made in order to seek comments from dissatisfied patients and to explore reasons for them, creating conditions to improve quality of care. Poor-quality of care is related to reduced patient satisfaction, but high patient satisfaction scores are not equal to high quality day case services.
Ambulatory Surgery has been organised in an unique way around the patient and not the dominant profession, radically changing all the health care system and the health professionals' behaviour. So, seeking for the patient opinion is obligatory for all day surgery units, not to justify their services, but to improve and better the quality of them . Results from several clinical studies show that there is higher patient satisfaction if:
- good post-operative pain control is achieved [4;
- there is no post-operative nausea and vomiting [31;
- good pre and post-operative information is delivered ;
- increased surgery availability and short waiting time before surgery are achieved;
- a courtesy and a friendliness environment are given by the operating and day surgery staff;
- patients do not feel that they are being discharged too early or in a rushed way;
- a telephone follow-up contact on the next day is established.
Patient satisfaction is quite difficult to measure. In addition, such subjective quality indicator depends on different civilisations, cultures, backgrounds, individual expectations, making its measurement and results a most difficult achievement. Thus, emphasis must be pointed out on the importance of assessing patient satisfaction across the continuum of ambulatory care with reliable, valid and feasible patient satisfaction questionnaires to our target population. Glenda Rudkin has developed a set of recommendations for improving the design of patient satisfaction questionnaires .
Guidelines for "improved design" in day surgery patient questionnaires: Reproduced from Rudkin GE 
- Define the target sample size, ensuring representatives and spread of conditions
- Do not exclude the "disadvantaged patient", e.g., non-native speaking
- Consider involving a neutral party to distribute the questionnaire. Health staff may bias the sample by omitting patients they judge to be unsuitable
- Respondents are less prepared to be critical if they know that the health staff will see their questionnaires
- Anonymity is important
- Consider designing a short, general questionnaire supplemented by subsidiary questionnaires where dissatisfaction is shown to occur
- Include open-ended questions, as they produce more negative ratings and comments than closed questions
- Consider qualitative research (in-depth interviews with patients) as a key input to the development of a pilot survey. Patient interviews reveal higher rates of problems than questionnaires
- 50% or less is not an acceptable response rate. Much higher rates should be achieved
- Follow-up cards or calls are recommended to improve response rates
- Response rate for mail surveys are significantly higher than phone surveys; however, there are more missing data from mail surveys
- Carers of relatives or friends may rate care more negatively than patients - patients and carers have differing needs. Separate questions to both groups may be appropriate
- Decide what you will do with the results. Disseminate the information to patients and staff.
- Publish the results
To have a more holistic and reliable result about all aspects of quality of care that reflects on patient satisfaction -i) the structure of the institution or day surgery unit; ii) the process that enable the services to be delivered; iii) and the outcome data must be collected specially in two different occasions, one in the immediate post-operative period (concerning the 2 first aspects) and the other around one month later to evaluate the global patient satisfaction including outcome .
Although targets are difficult to established on this particular subject, we suggest that a minimum of a 65% response rate and a 85% satisfaction score should be achieved by every day surgery unit.
 -Roberts L. Clinical indicators for quality assurance in ambulatory surgery. Ambulatory Surg. 1994;2:5-6.
 -Waghorn A, McKee M. Understanding patients' views ofa surgical outpatient clinic. J. Eval. Clin. Pract 2000;6:273-9.
 -Jenkins K, Grady D, Wong J, Correa R, Armanious S, Chung F. Post-operative recovery: Day surgery patients' preferences. British Journal of Anaesthesia 2001;86:272-4.
 -Scott NB, Hodson M. Public perceptions of post-operative pain and its relief. Anaesthesia 1997;52:438-42.
 -Beauregard L, Pomp A, Choiniere M. Severity and impact ofpain after day surgery. Can. J. Anaesth 1998;45:304-11.
 -Gan TJ, Sloan F, Dear G DL, EI-Moalem HE, Lubarsky DA. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesthesia and Analgesia 2001;92:393-400.
 -Rudkin GE. Balancing cost and quality in day surgery .In: Practical Anaesthesia and Analgesia for Day Surgery. J. Millar, GE Rudkin, M. Hitchcock eds. Bios Scientific Publishers, Oxford, 1997:227-235. -Tong D, Chung F, Wong D. Predictive Factors in Global and Anesthesia Satisfaction in Ambulatory Surgical Patients. Anesthesiology, 1997;87:856-64.