Running Head: CONSUMER PERCEPTIONS AND OUTCOMES 1 The relationships among quality of care, empowerment, and outcomes among psychiatric inpatients

Background: Consumer perceptions of care are a key measure of service quality. The Consumer Perceptions of Care (CPoC) survey is often used to assess patients’ evaluations of the quality of services received. Aims: The study explored the factor structure of the CPoC, the relationships among perceived quality of care, empowerment, perceived treatment outcomes, and symptom change, as well as the effect of allowing patients to self-identify during the CPoC survey on their ratings of perceptions of care. Methods: In the first phase of the current study, 2,125 psychiatric inpatients were surveyed about their perceptions of care and their symptoms were also measured at both admission and discharge. The second phase examined 720 inpatients that had given consent so that perceptions of care could be compared with outcome data. Results: Increased levels of empowerment were associated with favourable ratings of perceived treatment outcomes. Although perceived treatment outcomes and empowerment were correlated with actual symptom change, these correlations were small. Furthermore, the influence of selfidentification on ratings of perceptions of care was found to be small. Conclusions: Thus, examining patients’ perceived and actual treatment outcomes may provide mental health service providers with a more nuanced perspective of the hospital experiences of their patients. Consumer Perceptions and Outcomes 3 Relationships Among Quality of Care, Empowerment, and Outcomes in Psychiatric Inpatients Consumer perceptions of care can be used for quality assurance and improvement (Smith et al., 2014). Assurance that programs are being appropriately delivered provides a basis for evaluating outcomes and therefore, understanding a consumer’s perception of their care is an important component of evaluating the way a service delivers treatment. However, consumers’ perception of care is multifaceted. It is therefore important to understand the different components of perceptions of care and how these components relate to one another so that mental health service providers can respond to patient concerns effectively. However, at present, it is unclear as to whether consumer perceptions of treatment outcomes in mental health are primarily related to factors external to individuals (such as judgments about the quality and appropriateness of care received) or internal factors (such as a judgment that treatment has increased a sense of empowerment). A greater understanding of the factors underlying perceptions of care and perceived treatment outcomes can facilitate targeted responses to negative and positive service evaluations (Newbold, Hardy, & Byng, 2013). Measuring Consumer Perceptions of Care The Consumer Perceptions of Care Survey (Morris-Yates, 2009; Queensland Health, 2009) is based on the Consumer Surveys developed by the Mental Health and Statistics Improvement Program (MHSIP; Eisen et al., 2001; Jerrell, 2006). It was developed by Australian mental health facilities for the purposes of quality assurance and improvement. The Consumer Surveys demonstrated good reliability for the three factors of Access (α=.73), Quality and Appropriateness (α=.81), and Perceived Outcomes (α=.79; Jerrell, 2006), but they did not address patient empowerment, which has since arisen as an important factor in mental health Consumer Perceptions and Outcomes 4 recovery models (Bonney & Stickley, 2008). It was also apparent that not all questions were appropriate for the Australian cultural context and private-based psychiatric care. More recently, the Consumer Surveys were reviewed by consumers and carers in Australia, and were subsequently adapted into the Consumer Perceptions of Care (CPoC) survey. The CPoC was found to be acceptable to users and appropriate for rating clinical services. The content validity of the CPoC was also found to be acceptable (Morris-Yates, 2009; Queensland Health, 2009). However, despite describing general acceptability (Morris-Yates, 2009), the report did not ascertain the reliability of the instrument, nor the degree to which the items clustered into the three expected domains of Perceived Treatment Outcomes, Quality and Appropriateness and Empowerment). Hence, one key aim of the current study was to examine the factor structure of the CPoC using structural equation modelling. In the present study, “perceived treatment outcomes” will be used to refer to client self-reported changes in symptoms, daily function and crisis-management, wellbeing, and social function as measured by the CPoC. The “quality and appropriateness” of care refers to perceptions that services were delivered in a professional manner. Finally, “empowerment” will be used to refer to the extent to which individuals feel empowered to take control of their mental health problems. Empowerment is a concept that has been receiving increased attention within a mental health recovery model (Anderson et al., 1995; Arnetz, Almin, Bergström, Franzen, & Nilsson, 2004; Stack & Martin, 2005). According to Berry, Allott, Emsley, Ennion, & Barrowclough (2014), empowerment refers to taking personal responsibility, exerting control over life, and focusing on strengths (see also Berry, Allott, Emsley, Ennion, & Barrowclough, 2014), Consumers have been shown to regard being empowered as the most important factor for determining their own recovery (Grealish, Tai, Hunter, & Morrison, 2013), and factors such as daily routine, structure, and avoidance of inactivity are seen by consumers as means of increasing Consumer Perceptions and Outcomes 5 empowerment. Mental health providers often aim to facilitate routine, structure and minimisation of activity and therefore, the extent to which these are seen as empowering by patients may be associated with improved outcomes in both mental and physical health (Anderson et al., 1995). Given the absence of research investigating the measurement properties of the CPoC, it was first necessary to establish the factor structure of the instrument, which in turn would allow examination of the relationships between its expected domains (i.e., quality and appropriateness, empowerment and perceived treatment outcomes). Relationship of Perceived Outcomes to Symptom Change Existing research (Eisen et al., 2001; Jerrell, 2006) has revealed a strong correlation between quality and appropriateness and perceived treatment outcomes. However, since quality and appropriateness and perceived treatment outcomes are often measured at the same time, an individual’s current affective state may disproportionately influence their perceptions of the extent to which their symptoms have actually changed. As such, it is possible that there may be a weak relationship between perceived and actual treatment outcomes. The present study therefore sought to examine the relationship between retrospective patient ratings of treatment outcome on the CPoC and changes in symptoms between admission and discharge. One barrier to examining the relationship between symptom change and patient perceptions of care is the anonymous manner in which surveys are typically completed. To this end, patients in the present study were given the option of self-identification so that their clinical outcomes could be linked with the CPOC scores, which in turn permitted examination of the construct validity of the CPoC. However, a lack of anonymity in satisfaction surveys can also produce a response bias, where patients respond with ‘desirable’ responses if they believe that treating staff might access the data (LeVois, Nguyen, & Attkisson, 1981). Thus, the current study Consumer Perceptions and Outcomes 6 also examined the effects of allowing patients to self-identify on the CPoC on their ratings of perceptions of care. In summary, the current study had several broad aims. The first aim was to determine the factor structure of the CPoC. It was expected that the CPoC would have three factors: quality and appropriateness of care, perceived treatment outcomes, and empowerment. The second aim of the current study was to understand the relationships among quality and appropriateness of care, perceived treatment outcomes, and empowerment. In addition, the current study examined the relationships between these three constructs (measured at the end of treatment) and actual symptom change, operationalised as the pre-post treatment difference in symptoms. Finally, the current study aimed to determine whether there was a relationship between self-identification on survey responses, such that individuals who self-identified on the CFoC survey would exhibit more favourable perceptions of care than those who remained anonymous. Method Participants were patients at an Australian private psychiatric hospital who were invited to complete a CPoC questionnaire upon discharge between July 2010 and August 2012. In the first phase of the study, one group of patients was randomly selected from the total sample and their data was used for an exploratory factor analysis (EFA). The data belonging to the remaining group of patients were used to perform a confirmatory factor analysis (CFA). In the second phase, a subset of the total sample was extracted to examine the relationship between the perceptions of care data and symptom change from admission to discharge. Since these analyses required matching the perceptions of care with the symptom data, it was only possible to use the subgroup of patients who consented to have CPoC responses matched with their existing data. All participants provided consent for the data to be used for evaluation purposes. The CPoC was offered to all patients upon discharge from hospital. Patients could complete it Consumer Perceptions and Outcomes 7 anonymously or in a manner that allowed the CPoC to be linked with to existing clinical data (via a unique record number). If patients chose to self-identify, the CPoC data were linked with the clinical data by hospital staff and any identifying infor