{'fraction_non_alphanumeric': 0.02282608695652174, 'fraction_numerical': 0.00036231884057971015, 'mean_word_length': 5.040481400437637, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Measuring quality of dermatology care from the patient's perspective: how was it for you?

Unless you ask, you don’t find out. It is important to know patients’ opinions of their experience using dermatology services. Feedback may be uncomfortable, especially if it is not complimentary to you (or, worse, to me), but absolutely necessary. van Cranenburgh et al. in this issue of the BJD should therefore be congratulated for focusing our thinking on this. The patient’s experience is not only based on their encounter with the dermatologist. Accompanying a relative to outpatients recently, parking was difficult, in the waiting room we were subjected to a noisy, inane television programme (until I furtively switched it off, to general applause) and the status of the doctor we were to see was unclear. While waiting to have blood taken, we were crammed into an uncomfortably overcrowded waiting room, grimly checking our supermarket deli-counter style numbered tickets. So the patient’s frame of mind at the start of a consultation is already strongly influenced by a wide range of factors: it is clearly in the interests of all that that frame should be positive. We need feedback to identify problems and improve things. Clinicians and administrators may be blissfully ignorant of patients’ real views of their services. Patients may self-censor from a fear of appearing ungrateful, by a sometimes misplaced trust that ‘they must know what they are doing’. Or patients may think that expressing their views might adversely alter clinicians’ attitudes to them. There is, for example, a large discordance between patients’ and physicians’ views over the appropriateness of the decision to be discharged from dermatology outpatients, with dermatologists often unaware of patients’ surprise or anger over being discharged. Getting feedback by systematically gathering descriptive information will give useful guidance of what aspects need to be improved. But is it necessary to try to measure levels of satisfaction? If this were possible, then some uncomfortable possibilities could arise. Perhaps target scores could be identified that services should aspire to, or even be required to meet. Maybe scores might contribute to decisions over distribution of funding to different services, with higher-scoring units receiving more financial support. Perhaps some private clinical services would brag in their advertising about their high scores. Perhaps heath service authorities might bring in ‘special measures’ or close down a service if very poor scores persisted. Potentially uncomfortable for some service providers, and probably unwelcome to some, this might be a way of pushing up standards and benefiting patients. The Consumer Quality Index (CQI) has been used in some of these ways in the Netherlands: where hospitals were forced to publish their CQI results they responded by enhancing the experiences of their patients. It is easy to see the logical development of these ideas in dermatology. In seeking feedback, the questionnaire you choose to use or develop must be tailored to a specific, clear aim. If, for example, you want to assess the clinical effectiveness of a dermatology service, then it might be appropriate to use a quality of life tool. If you want to determine how much patients are benefiting from a dermatology service, then a measure such as the Patient Benefit Index may be best to use. But if you want to get information about the quality of care that patients consider they are receiving, then you need another type of questionnaire: van Cranenburgh et al. describe their novel Consumer Quality Index Chronic Skin Diseases (CQI-CSD) to fill this gap. The CQI-CSD is based on the CQI, but also on a literature review, interviews with patients and dermatology staff and focus groups. There are 65 questions that cover the following: health care provided by GP, accessibility of hospital; waiting times; hospital facilities; information about the care process; health care provided by physician; health care provided by nurses; cooperation of health care providers; information provision by health care providers; patient participation; safety; global rating of the hospital; skin complaints; and about the respondent. This list illustrates the complexity of trying to capture the details of how health care is experienced. Such a lengthy questionnaire is never going to be practical to use routinely with every patient, nor would the respondent burden be justified. However, the CQI-CSD could be very useful to help drive up standards. If used intermittently it could identify problems with a service and be used to assess change. This could detect newly arising problems in areas that were previously working well. The questionnaire could also be used to audit health care delivery and to compare different services. Although a stated aim was to compare different hospitals, van Cranenburgh et al. admit that the power of the CQI-CSD to discriminate between different hospitals was limited. It is likely that the varying structure of different services and the different information needs of service providers could best be met by questionnaires tailored to individual units. So maybe it would be useful to borrow the idea of core outcome sets from the Harmonizing Outcome Measures for Eczema initiative, and identify a minimal core set of questions, of ‘universal’ relevance, and add locally specific questions to this core. Data from a core question set could be used to compare and