Full text of DOI:10.1177/01632780022034480

USING FOCUS GROUPS TO
ASSESS PRIMARY CARE
PATIENTS’ SATISFACTION
Evaluation
Schwarz et al.
&
the Health Professions / March 2000
USING FOCUS GROUPS
/
The present report describes the use of patient
focus groups by a primary health care facility.
We review our rationale for using focus
groups and the process we used to prepare for
and conduct them. We then highlight the
results and lessons learned through this expe-
rience. Focus groups can be an excellent
method for primary care practices to assess
the complexities of patient satisfaction issues
and engage patients in the continuous quality
improvement process. Focus groups can
uncover unanticipated issues that surveys fail
to identify. Our experience demonstrated that
this benefit can be critical in identifying and
prioritizing quality of care improvements and
that focus group results can be used to make
immediate improvements in the quality of
care, even though this type of study is not
intended to generalize.
MIRIAM SCHWARZ
SUZANNE E. LANDIS
JOHN E. ROWE
CYNTHIA L. JANES
NAOMI PULLMAN
Mountain Area Health Education Center
AUTHORS’ NOTE: The authors gratefully
acknowledge the expertise and guidance pro-
vided by the Patient Satisfaction Improve-
ment Team in developing and conducting the
patient satisfaction focus groups. We wish to
thank specifically team members June Trevor,
M.S.W.; Beverly Berthelot; Joni Ellis, R.N.;
and Roger Jensen, M.D.
EVALUATION & THE HEALTH PROFESSIONS, Vol. 23 No. 1, March 2000 58-71
© 2000 Sage Publications, Inc.
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uccessfully improving quality depends on being able to under-
stand customers’ needs and expectations and then exceeding
S
them. When the delivery of medical care meets or exceeds customers’
needs and expectations, patients are more satisfied. And when patients
are satisfied with the care they receive, (a) they are more likely to con-
tinue seeking care at that health care facility, (b) they perceive their
quality of care to be high, (c) they are more likely to follow their pro-
viders’ instructions, and (d) they may be viewed as having adequate
access to care (Batchelor, Owens, Read, & Bloor, 1994; Bell, Kriv-
ich, & Boyd, 1997; Goldfield, 1996). Thus, patient satisfaction with
medical care is an important concept to track over time.
Measuring satisfaction is complex and multidimensional. The most
frequently used method of determining the degree to which patients
are satisfied with the services they are receiving is the patient satisfac-
tion survey. Unfortunately, survey results often fail to produce infor-
mation that is useful for program improvement (Williams, Coyle, &
Healy, 1998). One reason is that the information produced from sur-
veys is not discriminating enough to be helpful. Satisfaction depends
on the degree to which expectations have been met (Williams, 1994).
Assessing only the level of satisfaction without assessing associated
expectancies yields information that is limited in its ability to lead to
service improvement: Patient satisfaction surveys fall into this cate-
gory (Williams et al., 1998). A second issue is that providers may ask
for satisfaction ratings about areas (e.g., friendliness of staff, quality
of care, timeliness) that are not of greatest interest or importance to
patients (McComas, Kosseim, & Macintosh, 1995). Third, the typical
closed-ended, global survey may too narrowly frame the range of pos-
sible responses and may result in overestimates of satisfaction
(Batchelor et al., 1994). A related issue is that surveys often do not
give patients any real opportunity for input into how they would like to
have services provided (Batchelor et al., 1994). Fourth, the written
survey approach presents barriers to those patients who are less edu-
cated and literate, or for whom English is not the first language. The
use of questionnaires may discriminate against these groups (McIver,
1991).
Valid feedback on what patients expect and value in a health care
experience, how a health care facility measures those aspects of care
(Batchelor et al., 1994; McComas et al., 1995; Williams et al., 1998),
and what system changes patients would like to see (Nelson, 1993)
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Evaluation & the Health Professions / March 2000
would be more useful for service improvement. Patient focus groups
can provide valuable feedback about what patients expect, and they
are particularly effective in identifying factors patients find important
(Ford, Bach, & Fottler, 1997; McComas et al., 1995). Because the
questions are open-ended and amplification is invited, participants’
experiences, opinions, and suggestions are likely to be heard and
understood. The focus group setting communicates to patients that
they will be listened to and that their input is valued.
Focus groups have been suggested as very helpful in the develop-
ment and testing of new patient services (Smith, Scammon, & Beck,
1995), as well as the ongoing monitoring of existing services (Joint
Commission on Accreditation of Health Care Organizations, 1995),
but the emphasis in the literature is on using qualitative findings to
develop more customized quantitative surveys. Ford and his col-
leagues (1997; Fottler, Ford, & Bach, 1997), in a comprehensive
review of methods of measuring patient satisfaction, recommend that
health care organizations new to measuring patient satisfaction begin
with qualitative methods for issue identification, following up with
quantitative methods. For example, McComas et al. (1995) used focus
groups to identify aspects of care that were important to patients, then
constructed a questionnaire that reflected these issues.
Hospitals and large managed care organizations have led the way in
health care-related quality improvement efforts. A number of journal
articles have reported on hospitals’ and managed care organizations’
use of focus groups to understand patients’ perspectives (e.g., Nel-
son & Batalden, 1993; Nemeth, Hendricks, Salaway, & Garcia, 1998;
Smith et al., 1995). Increasing competition for patients, increasing
emphasis on satisfying customers’ needs, and improving quality of
care is resulting in more attention being paid to the expectancies and
needs of patients (Nelson & Batalden, 1993). Most primary care prac-
tices do not regularly employ mechanisms for measuring patient satis-
faction. The regular employment of systems for soliciting patient
feedback through focus groups can provide critical information to pri-
mary care facilities that could lead such organizations to better meet
customer needs while also meeting the facility’s objectives (Smith
et al., 1995).
Focus groups do have some drawbacks that are important to con-
sider when determining the best approach for measuring patient satis-
faction. Even with careful planning and a skilled research team, focus
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Schwarz et al. / USING FOCUS GROUPS
61
groups can be very expensive, time consuming, and labor intensive
(Ford et al., 1997). Costs may include paying a skilled facilitator, find-
ing a suitable location, providing incentives for attending, and helping
with child care and transportation. Recruitment of participants and
data analysis take time and are labor intensive. These issues must be
addressed up front.
The present report describes the use of patient focus groups by a
primary health care facility. We review our rationale for using focus
groups and the process we used to prepare for and conduct them. We
then highlight the results and lessons learned through this experience.
We emphasize that the information obtained from patient focus
groups can be used to make immediate changes that improve both sat-
isfaction and quality of care.
BACKGROUND
The Mountain Area Health Education Center (MAHEC), located in
Asheville, North Carolina, is an arm of the statewide Area Health Edu-
cation Center network overseen by the University of North Carolina at
Chapel Hill. Within MAHEC is housed a continuing medical educa-
tion division providing programs for health professionals from a 16-
county region of western North Carolina, a Women’s Health Center
providing ob-gyn medical care for women in the region, and a division
of family medicine (DFM) in which is housed the Family Health Cen-
ter (FHC), a family medicine practice. Both medical practices incor-
porate community practice-based residency programs. This work was
based at the FHC, which has a staff of some 125 people, including nine
full-time faculty physicians, two behavioral medicine faculty, and 24
community practice-based family practice residents.
The medical director of the FHC established an interdisciplinary
Patient Satisfaction Improvement Team in the late fall of 1995. The
team was charged with exploring patient satisfaction with the FHC to
help guide the future development of the center. The team was central
to the dat-gathering efforts of the DFM’s fledgling continuous quality
improvement (CQI) program. The team comprised physician faculty,
business office staff, nursing staff, and CQI/research staff, all of whom
were included to help develop and implement the team’s data collec-
tion plans.
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Evaluation & the Health Professions / March 2000
RATIONALE FOR USE OF FOCUS GROUPS
The team’s objective was to obtain from patients themselves infor-
mation on which specific action could be taken to improve existing
services and to help devise additional services. Initially, the team con-
sidered conducting a written survey to elicit patient ratings about ser-
vice delivery at the FHC. Our past experiences with written surveys
had resulted in poor response rates because of the less educated and
literate nature of key segments of the FHC patient population. Written
surveys also produced superficial data of limited use in decision mak-
ing. A key deficiency of written surveys and one-to-one interviews is
that the structured questioning that is typically used relies on the inter-
viewer’s or surveyor’s preconceived notion about what is really
important to the respondent. Although we thought we knew what the
key issues were, we wanted the flexibility to explore in depth with
patients issues we had not anticipated. We also wanted to provide an
environment in which patients would feel comfortable enough to dis-
cuss issues candidly with one another. For these reasons, the team
chose to use focus groups.
PREPARING FOR THE FOCUS GROUPS
SELECTION OF TARGET GROUPS
Once it was agreed to gather data by conducting focus groups, the
next step was to define the representation needed to successfully
explore topics of interest to the FHC’s major consumer groups. Four
patient groups were defined: (a) pregnant women and families with
children (this group would be of mixed payer status with Medicaid
recipients included), (b) people with private insurance or with a health
maintenance organization (HMO) up to age 65 who were working
people and professionals, (c) people 65 and over, or with disabilities,
who use Medicare, and (d) African Americans. Each of these groups
was of particular interest to us, some because they represent large por-
tions of our patient population, others because they are groups we need
to attract to our practice. Because ours is a teaching practice within a
family practice residency program, it is important for us to attract
obstetric and pediatric patients to the FHC so that we can maintain a
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Schwarz et al. / USING FOCUS GROUPS
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mix of patient types for our residents. Our practice comprises over
50% Medicare and Medicaid patients, so we wanted to be sure that
they were well represented in the focus groups. The private insurance
sector/HMO group was invited because of our interest in assuring that
we were doing all we could to satisfy their needs. And finally, as part
of an organization-wide effort to increase our diversity, an African
American group was added because we had learned through other
patient focus groups we were running elsewhere in MAHEC that some
issues related to racism and discrimination had been brought up in an
all-AfricanAmericangroupthatwerenotraisedintheall-whitegroups.
RECRUITMENT OF PARTICIPANTS
Patients meeting one of the group definitions described above were
recruited through faculty physicians, residents, and clinical staff.
These sources were asked to recommend information-rich (Patton,
1990) patients who would be willing and able to air in a balanced way
their likes and dislikes about being a patient at the center. We recog-
nized the possibility of selection bias, but this was thought to be the
most efficient, cost-effective means of recruiting patients.
Once potential participants were identified, their physicians were
asked to recruit the patients in person if their next appointment was
within the month. At the appointment, the physicians presented the
patients with letters of invitation that provided details about the focus
group. Patients who did not have an upcoming appointment scheduled
were sent the letter of invitation in the mail. A follow-up phone call
was made and, if the patient agreed, a flyer was sent that confirmed
their participation and provided the details of the particular focus
group session.
LOCATION AND INCENTIVES
The focus groups were held in the spring and summer of 1996 and
were held away from the FHC to provide a neutral, confidential envi-
ronment. The pregnant/families group was held at a centrally located
church with day care facilities. Child care was provided for this group.
A complete meal was provided for each group, and each participant
was given a $10 gift certificate to a local grocery store. All groups
were held at times of greatest convenience for participants; for
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Evaluation & the Health Professions / March 2000
example, they were held in the morning for the Medicare group, which
was largely made up of retirees, and in the early evening for the work-
ing insured. Transportation (taxi service) was provided for several
Medicare group members.
CONDUCTING THE FOCUS GROUPS
FOCUS GROUP STAFFING
The moderator for the four focus groups was an M.S.W. candidate
at the University of North Carolina at Chapel Hill who, at the time,
was serving an internship with MAHEC’s Community Health
Resource Services Department. She had been the project coordinator
of the Madison Community Health Project in western North Carolina
and had helped conduct numerous community-based focus groups.
She had written about using focus groups as a research tool and had
helped to conduct workshops on the subject. She was deemed an
appropriate choice as moderator because of her extensive experience
with focus groups, her neutrality, and her willingness to do this work
free of charge. One staff person coordinated the recruitment of partici-
pants and logistics. She also took notes and handled audio recordings
at each session. The CQI coordinator was present at three of the
groups as an observer and also took notes. An African American staff
member was recruited to serve as co-leader in the African American
focus group.
FOCUS GROUP PROTOCOL
The focus group methods, introduction, ground rules, guidelines,
questions, and prompts for specific topics of interest were developed
in close collaboration with the Patient Satisfaction Improvement
Team. We used Kreuger’s(1994) FocusGroups: A Practical Guide for
Applied Research as a guide. Our introduction included a statement on
confidentiality. We assured participants that no names would be
attached to our documentation. We obtained their verbal permission to
tape-record the session, assuring them that we would erase the tape
after the information was extracted from it. We also decided that we
would consult with and seek permission from specific participants if
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Schwarz et al. / USING FOCUS GROUPS
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we used direct quotes in our report that might render those patients
identifiable.
PILOT FOCUS GROUP
A pilot group was organized that consisted of MAHEC employees
from another building who were also FHC patients, to pretest the
focus group questions and the process. Debriefing questions were
designed for use with the MAHEC staff pilot group to solicit feedback
about the process.
DESCRIPTION OF PARTICIPANTS
In total, 32 patients participated in the five focus groups. Most of
the participants had been FHC patients for a considerable period of
time (5 years or longer and, in some cases, 15 to 20 years). During the
sessions, patients connected well and seemed to enjoy meeting and
talking to one another, even exchanging telephone numbers. Many
participants told us that they were surprised and honored to have been
asked to be in a focus group and greatly appreciated the opportunity to
contribute their ideas. Initial groups were scheduled tolast anhourand
a half, but with meals being served and the level of participation and
involvement witnessed in the pilot group, subsequent sessions were
scheduled for 2 hours.
PROCESS OF ANALYZING RESULTS
During the sessions, the moderator summarized key comments
made by participants to verify accuracy and completeness. Partici-
pants were given a copy of the focus group questions and were encour-
aged to write down and submit anonymously in an envelope issues or
concerns that they were not comfortable sharing with the rest of the
group. Staff met immediately after each session to debrief, discuss the
most important themes, noteworthy quotes, and unexpected findings;
to compare themes with those from other groups; and to make any
revisions to the process that might be needed for future groups.
Staff developed initial verbatim transcripts from tapes and field
notes. Transcripts were mailed to participants for review and veri-
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Evaluation & the Health Professions / March 2000
fication of accuracy. The moderator, note taker, and CQI coordinator
then independently conducted content analysis of the raw data and
identified emerging categories and themes. These independent find-
ings were compared and consolidated into a final report, which
included a description of the process and areas for improvement. Also
included were patient recommendations for solutions. This report was
circulated to all faculty, residents, and staff at the FHC through formal
presentations and at group meetings. The Quality Council, which
oversees the CQI process at the center, made recommendations based
on the findings, as did faculty, residents, and staff.
Following the focus groups, participants were kept informed of the
implementation process through memos from the DFM’s director.
The following fall, a phone survey was conducted with a sample of the
participants to gauge whether they had noticed changes we had made
and if new issues were emerging.
RESULTS
The interchange between patients was key in identifying unantici-
pated high-priority quality issues. For example, our practice regularly
uses video cameras in exam rooms so that faculty can monitor the resi-
dent physician/patient encounter. Although we did not ask them about
cameras, the patients raised questions about their use. There was con-
fusion about when the cameras were on and what the role of the patient
was in the use of the cameras. Our center policy was not being clearly
communicated or understood by patients. Because this issue was
raised spontaneously in four out of five groups and was an important
issue of patient trust, priority was given to immediately implementing
improvements. The information was passed on to the center’s behav-
ioral medicine team, which revised the consent statement provided to
new patients. A procedure was developed to ensure that all new or
returning patients being monitored by the camera understood and
signed the form.
Another example of an important unanticipated concern was the
issue of test results. When describing what they liked about the FHC,
some patients expressed great satisfaction with the way test results
were communicated, stating that they got all test results (both normal
and abnormal) with ample physician comments/explanation. On
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hearing this, others shared their experiences with receiving test
results, and these experiences varied widely. Of those who got their
results, some were notified by phone calls, some by mail, and some
were asked to call in to the office to hear results. Some patients
received little or no explanation of their test results. Some obtained
results long after they expected to get them. Others never learned of
their results at all. Many patients in the groups expressed surprise and
dismay on hearing that their experiences were so varied.
The discussion within the focus groups identified for us the wide
variation in how we distributed test results to patients. These patients
concurred that they wanted to be informed of both positive and nega-
tive test results in a reliable, predictable way. On learning of the
patients’ consensus and recommendations, providers acknowledged
that the variation in reporting test results was a significant quality of
care issue warranting immediate attention. A CQI team was formed to
improve the process used to inform patients of their test results.
One of the major benefits of the patient focus groups was that we
were able to use the results to make immediate improvements in the
quality of care. Although focus group results are not to be generalized
to the entire population, they can certainly point to systems issues that
need attention and improvement. Kreuger (1998) notes,
In a strict sense, one cannot generalize, but what we suggest is the con-
cept of transferability. . . . Those who seek to use the results [should]
look over the study; examine the procedures, methods, and analysis
strategies and then decide the degree to which the [findings] might be
applied to their situation. What may be transferred are the larger theo-
retical concepts, as opposed to the specific behaviors. (p. 70)
Concerns were raised in our focus groups that were so obviously fun-
damental to good service that additional verification was not needed:
Implementation just made good common sense. Older patients and
others with mobility problems brought up the heaviness of the front
doors of the clinic. The doors were reworked. Mothers of infants
described how hard it was to change diapers in a crowded waiting
room or on a bathroom floor. A changing table was added to the
women’s restroom (expense prohibited placing one in the men’s
restroom). Our waiting room reading material was said to be limited in
scope. Subscriptions to magazines that reflected the clinic’s diverse
patient population were ordered. Difficulty finding one’s way around
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Evaluation & the Health Professions / March 2000
the clinic was raised. Directional signs were installed to guide patients
to key clinic sites such as the lab. Telephone access to the clinic was
problematic; phone lines were added to the phone system. Not all staff
were identifying themselves to patients; name badges were issued to
all employees, and the wearing of badges was strongly encouraged.
Prescription refills were difficult to obtain; the phone system was
redesigned, and refill phone lines were established. All of this infor-
mation helped emphasize the importance of patient feedback in the
quality improvement process and helped staff understand the need to
include this kind of information in the process.
Other, more complex issues required additional research before
further action was taken. Often, these topics were assigned to various
CQI teams and committees for further investigation. Focus group par-
ticipants had a number of recommendations for attracting more
obstetric and pediatric patients to the clinic. Their comments were for-
warded to the FHC Marketing Committee for further assessment,
resulting in the establishment of childbirth classes at the facility. The
issue of waiting times, both in the waiting room and the exam rooms,
was raised in the focus groups, but the perceptions about them were
inconsistent. For example, some felt that the FHC provided the ideal in
wait times and were very satisfied. Others had occasional lengthy
waits, but that was not their experience in general. Still others were
satisfied with the wait time in the waiting room but felt the time in the
exam room was excessive and wondered why they could not have
remained in the waiting room. The information we received left us
with an unclear picture of the level and focal point of concern. The
Patient Satisfaction Improvement team subsequently conducted a tar-
geted written patient survey on wait times, which provided broader
input on details about actual and expected wait times. The results sug-
gested general satisfaction with FHC wait times.
This was our practice’s first venture into using focus groups as a
means to collect patient data. We kept track of the time it took us to
plan, conduct, and analyze data from four focus groups plus the pilot
group. It took us a total of 267 hours to complete this work. This
included 147 hours for planning (including Patient Satisfaction team
meetings, literature reviews, research on focus groups through read-
ings and workshops; design of focus group questions; preparation of
the introduction and ground rules; participant recruitment; and logis-
tics such as child care, food, incentives, and transportation); 100 hours
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Schwarz et al. / USING FOCUS GROUPS
69
for conducting the focus groups (setting up the sites, moderating the
groups, taking notes, cleaning up, debriefing, developing initial tran-
scripts, analyzing the data); and 20 hours for the final report (writing,
editing, reviewing, copying, distributing, discussing). We estimated
that if we were to repeat the same process again, the time needed for
planning could be cut by 40% to 50% because we now had experience,
a clear process, and prepared materials on our side.
Other than the time that the process took, there were some difficul-
ties along the way. Identifying eligible patients who were likely to pro-
vide a balanced view of the practice without bias was challenging. It
was anticipated that physicians and staff would be likely to select peo-
ple who would have a tendency to say good things about us. Given the
nature of our practice, where a 15% to 20% no-show rate is common
and the literacy rate variable, and because of the large amount of time
and expense expended on this project, we felt we could not rely on a
random selection of patients, as half the people might not show, and
the others might have little to say. We acknowledged that we were
introducing a source of bias, but the information gained was useful in
improving systems. We did try to include those who might be dissatis-
fied with some particular services or procedures, knowing that they
would have important views and feedback for us. It was a challenge to
coordinate the logistics of getting physicians to identify patients and
inviting patients to participate. This added a considerable amount of
time to the process.
Although our focus group research study was time consuming, this
effort marked a turning point for our practice in using patient data to
make quality improvements. For the first time in our practice’s history,
we collected and then followed up on patient satisfaction data in an
organized, thorough manner. The richness of the resulting data proved
exceptionally useful in making immediate, meaningful improvements
to our practice. The focus group data also provided us direction for
further needs assessments where the issues were more complex.
Meeting with the patients in person and hearing them express them-
selves made us feel even more connected to them and heightened our
commitment to respond to the issues they raised. The staff involved in
the focus group study found the experience rewarding. We enjoyed lis-
tening to our patients, and we found their enthusiasm and level of
involvement gratifying. All involvedinthe effort felt the time waswell
spent. Because of this experience, the practice decided to continue
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Evaluation & the Health Professions / March 2000
using focus groups as its primary means of collecting comprehensive
and meaningful information on the status of patient satisfaction. We
are now in the process of conducting our second focus group study.
CONCLUSION
Focus groups can be an excellent method for primary care practices
to assess the complexities of patient satisfaction issues and engage
patients in the CQI process. Focus groups can uncover unanticipated
issues that surveys fail to identify. Our experience demonstrated that
this benefit can be critical in identifying and prioritizing quality of
care improvements and that focus group results can be used to make
immediate improvements in the quality of care, even though this type
of study is not intended to generalize.
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