Introduction

In every organization or institution, there are numerous processes that operate and interact
with each other in order to meet organisational goals. It is critical for these processes to be
evaluated to ensure that they meet the desired quality requirements. Quality evaluation and
improvement consequently requires the input of “customers” regarding these processes and
this can be done through a research technique called Voice of the Customer (VoC)
(Coppenhaver 2018). In healthcare, the end customer are the patients and their input are
important in adapting processes that directly involve them. Gathering input, in this regard, is
best realised through partnering with patients or clients. The Australian Commission on
Safety and Quality in Health Care (2012) also asserted that partnering with patients or clients
not only constitute to high quality care but also contribute to the overall improvement in the
healthcare system. The organisation reflected this in the Standard Two of the National Safety
and Quality Health Service also known as Partnering with Consumers. This academic report
will revolve around the abovementioned directive and in the chosen clinical context of wound
care. Evidence based literature will then be concurrently utilised to construct a survey and
semi-structured interview as guided by the processes in the Voice of the Customer (VoC)
method.

Review of Background Literature

Wound care management is a multifaceted practice that requires an evidence-based and

individualised approach (The Future of Patient-Centered Wound Care 2017). Clinicians
must be equipped with the necessary competencies and resources to tackle wounds especially
those identified as chronic and complex (Dowsett 2008). However, the success of wound
management does not solely depend on the competence of the clinician nor on the
appropriateness of wound products but also on the involvement of the person with the wound
(The Future of Patient-Centered Wound Care 2017). Studies reveal that full participation of
patients in their care have a positive impact on their health status and improves care delivery
(The Future of Patient-Centered Wound Care 2017). Developing a considerable degree of
patient involvement, nevertheless, falls onto the hands of the managing clinician (Dowsett
2008). Incorporating partnerships with patients or their carers in wound management by a
clinician is indeed significant in this realm.

1
In the context of the Australian healthcare system, incorporating patient partnerships in care
is one of the requirements to ensure that patients are removed from harm and receive quality
care (ACSQHC 2012). This concept of care delivery, as aforementioned, is expressed in
Standard Two of the National Safety and Quality Health Service Standards. Standard Two
particularly pushes for healthcare systems to have schemes in place to assist the workforce to
cultivate partnerships with patients, their carers or other consumers (ACSQHC 2012).
Effective partnerships with patients or consumers, then, translates to more efficient healthcare
systems and positive health outcomes (ACSQHC 2012). The Standard further affirms that
partnerships are present when consumers are given with respect and dignity, when informed
choices are promoted and when there is full-participation of consumers in their own care
(ACSQHC 2012). These general conditions can be achieved through the suggested
implementation strategies outlined in the published document regarding Standard Two
(ACSQHC 2012). One echoing theme in the implementation strategies is that feedback is
always gathered from consumers to evaluate an organisational procedure or process
(ACSQHC 2012). Accurate and appropriate collecting of consumer feedback is essential in
not only meeting the aim of patient centred care but also provides information to the
organisation on how it can ensure the quality of its processes (Daaleman et al. 2014).

Accurately capturing consumer feedback can be carried out using the Voice-of-Customer or
VoC method. This technique involves the use of a critical analysis process in gathering
specific consumer requirements regarding an organisational product or process (Aguwa,
Monplaisir & Turgut 2012). It specifically requires the use of qualitative and quantitative
research methodologies to gather consumer data (Teehan & Tucker 2010). Information
gathered is then synthesised and prioritised into a hierarchal list of consumer needs and
preferences (Aguwa, Monplaisir & Turgut 2012).

Methodology

The primary methodology involved in this academic report is a simple systematic literature
review. By definition, a systematic literature review is a method of analysing a range of
published articles or research studies in order to provide a synthesised response to a
hypothesis (Boland, Cherry & Dickson 2017). Systematic reviews are guided by a search
criteria in order to define the scope of literature inclusion (Boland, Cherry & Dickson 2017).
The keyword search criteria for this report are as of follows: “patient-centred care”, “wound
care management”, “patient-centred wound care”, “partnerships with patients and

2
consumers” and “Voice of Customer”. The synthesised body of literature is then used to
formulate and design a consumer survey and semi-structured interview based on the Voice of
Customer method. The research titled “A hands-on experience of the voice of customer
analysis in maternity care from Iran” was utilised as a close guide about the process of
conducting a Voice of Customer Analysis (Aghlmand, Lameei & Small 2010).

Results (The Voice of Customer Process)

1. Identification of the pertinent consumer segment

The first step in the Voice of Customer process is recognising the key consumer segment of
the process under scrutiny (Aghlmand, Lameei & Small 2010). In order to realise this, the
process needs to be dissected according to its components and these are: suppliers, input,
process, output and the customer (Aghlmand, Lameei & Small 2010). This academic report
focused on the general wound care management process regardless of the care setting. A
SIPOC (Supplier, Input, Process, Output and Customer) diagram was constructed to magnify
the components of the process and specify the key customer segment (Shankar 2009). The
SIPOC diagram is labelled below as Figure 1. The key customer or the end-user identified in
the process is the Patient with the wound. Other customers or stakeholders include the Health
Care Practitioner and the Care Coordinator.

Figure 1 SIPOC diagram of a Generic Wound Care Management Process

3
 2. Develop a Critical to Quality (CTQ) Tree

After recognising the key consumer, the next step on the process is constructing a Critical-to-
Quality Tree. The Critical-to-Quality (CTQ) tree is an instrument that focuses on the needs
and requirements of the relevant consumer by transforming broad output qualities into
specific measurable attributes (Cox et al. 2016). It gives the examiner a better understanding
on what qualities of the process are important to the consumer (Cox et al. 2016).

In terms of the process in scrutiny, literatures were examined to determine the consumer’s
need in wound care management. The general consensus of literature indicates that there is a
need for a health deficit to be eliminated or improve (Cox et al. 2016). Thus, the key
consumer is expected to receive quality health care or, in this case, quality wound care
management to satisfy that need. The next step in translating that need into a more specific
quality measure is to identify factors that must be present in order for consumers to perceive
that high quality service is being delivered (Cox et al. 2016). These factors are termed
“Quality Drivers” (Cox et al. 2016). In a Delphi expert consensus research, quality indicators
surrounding the care of chroming leg ulcers were identified and three themes surfaced in
regards to wound care quality (Augustin et al. 2011). These themes that directly correlate to
quality wound management are safe and effective interventions, patient centred care and cost-
effectiveness (Augustin et al. 2011). In this regard, these three factors are identified as the
“Quality Drivers” to meet the critical consumer need. These parameters, however, are still
broad to be accurately measured in a process which is why it is still necessary to determine
requirements that would meet these quality drivers (Cox et al. 2016). Performance
requirements of the process should have the characteristic that it can be quantitatively or
qualitatively measured (Cox et al. 2016). In this way, quality wound care management can be
specifically defined.

Safe and effective care is one of the hallmarks of healthcare as it is reflected in the National
Safety and Quality Health Service Standards. In regard to wound care, safe and effective care
translates to several key components. A study regarding the structural quality indicators of
chronic wound care in Dutch nursing homes highlighted that utilisation of an approved
protocol or guideline for prevention and treatment constitute to safe wound care (Rondas et
al. 2015). Moreover, an improvement and prevention of further harm on the wound is
observed as an intervention outcome (Augustin et al. 2011; Rondas et al. 2015). Wound care

4
interventions should also be delivered by a competent wound care clinician (Rondas et al.
2015).

Quality wound care does not only constitute safe and effective interventions. Patient centred
care is also one of the key drivers for the consumer need. As mentioned beforehand, patient
centred wound care leads to positive health outcomes and efficiencies to care delivery (The
Future of Patient-Centered Wound Care 2017). In Australia, the foremost guide in
establishing patient centred care is Standard Two of the National Safety and Quality Health
Service Standards (ACSQHC 2012). The standard generally identified that patient centred
care comprises of treating the patient consumer with respect, information is being exchanged
between the consumer and the clinician, and active participation in care is fostered if the
consumer is able (ACSQHC 2012). As this relates to wound care, wound clinicians are
expected to include the consumer is decision making, inform about aetiologies and treatment
options as well as addressing knowledge gaps in easy-to-understand terminology (Lindsay, E.
et al. 2017). Overall wound improvement directly correlates to the extent of self-directed
interventions actuated by consumers since they have full control of internal factors which has
a greater influence on wounds (Lindsay, Ellie 2014).

The third quality driver relates to the cost-effectiveness of wound care management. Due to
the nature and resources involved in wound care management, delivery of cost-conscious
services is identified to be a factor in the delivery of quality care (Milne 2016). Wound care
resources, such as dressings and cleansing agents, are particularly expensive which is why it
is necessary for treating clinicians to appropriately select a resource that will address the
clinical presentation (Milne 2016). Another aspect to consider in cost effectiveness is
obtaining the most accessible resource to eliminate overhead and other associated costs
(Milne 2016).

Following the synthesis of inputs discussed above, a Critical-to-Quality tree is constructed

and displayed below:

5
 Need Drivers CTQs

Evidence-Based interventions

Safe and Harm is prevented, and therapy is effective

Effective (Improving wound status)

Delivered by a competent clinician

Dignity and Respect is upheld

Patient Adequate information is exchanged between

Quality Wound Care
Centred consumer and clinician
Management
Active participation in care is fostered when
able

Appropriate use of wound resources (Right

dressing for the wound)

Cost Effective Accessible resources are prioritised

Figure 2 Critical to Quality Tree for Wound Care Management

3. Semi-structured interview and survey design

The accomplishment of the Critical-to-Quality tree provides direction on constructing data

collection methods to capture Voice-of-Customer data. For the purpose of this report, the data
collection methods will include a semi-structured interview and a survey. The construction of
a two different data collection method will enable the use of a two-step approach which can
provide a better understanding of the process.

a. Semi-structured interview

A semi-structured interview is a form of qualitative data collection technique which captures

the perception of stakeholders regarding a phenomena or a process (Edwards & Holland
2013). The distinct aspect of semi-structured interviews lies on the combination of

6
predetermined array of interview questions and the possibility of further exploring subjects or
themes (Edwards & Holland 2013). In other words, open- ended questions particularly
comprise semi-structured interviews which allows for further exploration on themes that
surround the process (Kallio et al. 2016).

In the Voice-of-Customer process, semi-structured interviews are conducted with customers

or stakeholders in the identified process with the purpose of capturing the perception of
customers regarding current process performance in relation to a measurement standard
(Gawthrop & Gopal 2017). The stakeholders that are the selected subjected for the interview
are the Health Care Practitioners and the Clinical Coordinator. Other stakeholders that have
an indirect influence on the process can also be considered for interview in light of expert
advice (Coppenhaver 2018). In this regard, a specialist clinician on wounds and an
overarching service manager can be included in the pool of interviewees. The interview
structure is optimally recommended to contain four to six questions and the duration should
run for twenty to thirty minutes (Kallio et al. 2016). For the output of this report, six
questions are constructed, and the pre-determined interview length is aimed at twenty-five
minutes. The Critical-to-Quality tree constructed in this report defines the measurement
standards or performance goals that will be central to the interview. Specifically, there are
two questions allocated per "Quality Driver".

The Semi-Structured Interview related to the Wound Care Management Process

Quality Driver 1: Safe and Effective care
1. What is your perception regarding the current wound care process in relation to
safety?
2. What should comprise of effective and quality wound care?
Quality Driver 2: Patient Centred Care
1. What are the attributes present in the current wound care process that reflect
patient-centred care?
2. How can active participation be fostered in the current wound care process?
Quality Driver 3: Cost-Effective Care
1. What are the costs associated in the wound care process?
2. How can accessibility of resources affect costs in the process?
Table 1 Semi-structured interview questions

The information obtained through Critical-to-Quality tree construction and semi-structured

interview will provide insight on the current process dynamics (Teehan & Tucker 2010). In
spite of this, the information gathered is qualitative and fuzzy which may be insufficient in
effectively evaluating the process thereby warranting an accurate data collection method
(Teehan & Tucker 2010).

7
 b. Survey design

After capturing the qualitative Voice-of-Customer data, the next logical phase is to capture
information that can be accurately gauged and representative of the broader key consumer
segment (Gawthrop & Gopal 2017). In other words, data collection will now involve the end
user or, in this case, the patients. The purpose of which is, again, to measure current
performance against the Critical-to-Quality factors identified (Gawthrop & Gopal 2017). A
cross-sectional snapshot of the process in motion can be obtained through a survey (Kelley et
al. 2003). The survey method will be used to realise that aim. This method of data collection
involves the use of a standardised form either with a questionnaire or an interview presented
with specific response (Kelley et al. 2003). For this academic report, a questionnaire survey is
constructed with a four-point Likert Scale response configuration. The numeric Likert Scale
captures the perception of the consumers quantitatively which then fulfils the purpose of this
step of the Voice-of-Customer process (Teehan & Tucker 2010). The construction of the
questionnaire survey was heavily guided by published literature relating to wound care,
Standard Two of the NHSQS and the Critical-to-Quality Tree. In particular, Table One or the
first section of the survey proper pertains to the performance requirements of Patient Centred
and Safe and Effective Care. Questions one to nine reflects to the former whilst questions ten
to twelve relates to the latter. The questions in Table Two, on the other hand, relate to the
Safe and Effective and Cost-Effective performance requirements. Questions one to two
reflect the former and the rest of the questions relate to cost-effectiveness.

The Wound Care Management Consumer Survey Questions

PART ONE: Demographics

1. Age in years?

2. Gender?

3. How long have you been having wounds?

4. How long have you been having wound treatments.

PART TWO: Survey Proper

Wound Care Management Consumer Survey

Strongly Agree Disagree Strongly

8
 Agree Disagree
1. I feel that my individual needs are
always taken into consideration with
regards to my wound care
2. I wholly participate along with my
carers (if appropriate) into the planning
and management of my wounds
3. I receive adequate information about
what is happening with my health
status especially with my wounds
4. I am made aware of wound treatment
options available to me
5. I am made aware of the benefits, side
effects and risks associated with my
wound care treatments
6. My contribution is asked regarding
the improvement of current wound
practice
7. I feel that I am regarded as whole
person and not a person with a “hole”
8. I am made aware of the costs
associated with the current treatment of
my wounds
9. I am made aware of any self-directed
interventions that will help in healing
my wounds
10. I feel that my current wound
regimen is safe
11. I feel that the overall approach to
my wound status is well contemplated
upon by clinicians
12. I am made aware of the basis of the
treatment being pursued for my wounds

9
Table 2 Wound Care Management Survey section

Wound Care Management Consumer Survey

Please describe how you feel Very Satisfied Somewhat Unsatisfied
regarding the following aspects of Satisfied Satisfied
wound care
1. Competence of the clinician caring
for my wounds
2. The healing progress of my wounds
3. The suitability of the cleansing
solution and technique used
4. The appropriateness of wound
dressings used
5. The duration and frequency of
wound treatments
6.The sustainability of resources in
place for my wound care or the cost-
effectiveness of my current treatment
Table 3 Wound Care Management Survey section 2

Summary

Healthcare have numerous inter-related processes that directly and indirectly affects different
stakeholders. Process evaluation and improvement is thus warranted to maintain equilibrium
in this sector. In this regard, this academic report highlighted process evaluation and
improvement in wound care management through the use of Voice-of-Customer analysis.
This technique involves the use of a step-by-step process in determining critical components
of a process and then analysing them through the insight of key stakeholders. This academic
writing identified key consumers of the wound care management process as well as
performance requirements for the process. Instruments were then constructed in the form of a
semi-structured interview and a questionnaire survey to evaluate current performance against
requirements. No data collection was made in this report. In addition, the Standard Two of
the National Safety and Quality Health Service Standards was used as an overall guide in the
process of Voice-of-Customer analysis. Its criteria and principles were applied in the
construction of the data collection techniques.

10
 References

Aghlmand, S, Lameei, A & Small, R 2010, 'A hands-on experience of the voice of customer
analysis in maternity care from Iran', International Journal of Health Care Quality
Assurance, vol. 23, no. 2, pp. 153-170.

Aguwa, CC, Monplaisir, L & Turgut, O 2012, 'Voice of the customer: Customer satisfaction
ratio based analysis', Expert Systems with Applications, vol. 39, no. 11, pp. 10112-10119.

Augustin, M, Rustenbach, SJ, Debus, S, Grams, L, Munter, KC, Tigges, W, Schafer, E &
Herberger, K 2011, 'Quality of Care in Chronic Leg Ulcer in the Community: Introduction of
Quality Indicators and a Scoring System', no. 4, p. 321, via edsbl (EBSCOhost),
<https://login.ezproxy.utas.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=tr
ue&db=edsbl&AN=RN297753019&site=eds-live>.

Australian Commission on Safety and Quality in Health Care 2012, Safety and Quality
Improvement Guide Standard 2: Partnering with Consumers, ACSQHC, Sydney.

Boland, A, Cherry, G & Dickson, R 2017, Doing a Systematic Review: A Student's Guide,
SAGE Publications.

Coppenhaver, R 2018, From Voices to Results - Voice of Customer Questions, Tools and
Analysis: Proven techniques for understanding and engaging with your customers, Packt
Publishing.

Cox, I, Gaudard, MA, Ramsey, PJ, Stephens, ML & Wright, L 2016, Visual Six Sigma:
Making Data Analysis Lean, Wiley.

Daaleman, TP, Shea, CM, Halladay, J & Reed, D 2014, 'A method to determine the impact of
patient- centered care interventions in primary care', Patient Education and Counseling, vol.
97, no. 3, pp. 327-331.

Dowsett, C 2008, 'Patient involvement in the management of leg ulcers', Nursing Times, vol.
101, no. 24, pp. 52-53.

Edwards, R & Holland, J 2013, What is Qualitative Interviewing?, Bloomsbury Publishing.

11
The Future of Patient-Centered Wound Care, 2017, The Angiogenesis Foundation,
WashingtonDC,<www.angio.org/wpcontent/uploads/2014/02/WoundCare_WP_27Feb2017_
ML.pdf>.

Gawthrop, J & Gopal, S 2017, 'Streamlining the Voice of the Customer: A study exploring
Voice of the Customer at Company X', Masters in Business Administration thesis, Blekinge
Institute of Technology.

Kallio, H, Pietilä, AM, Johnson, M & Kangasniemi, M 2016, Systematic methodological

review: developing a framework for a qualitative semi‐structured interview guide, 0309-
2402.

Kelley, K, Clark, B, Brown, V & Sitzia, J 2003, 'Good practice in the conduct and reporting
of survey research', International Journal for Quality in Health Care, vol. 15, no. 3, pp. 261-
266.

Lindsay, E 2014, 'Who's in charge? Towards a revolution in patient engagement in wound

care', Wounds U K, vol. 10, no. 1, pp. 18-20.

Lindsay, E, Renyi, R, Wilkie, P, Valle, F, White, W, Maida, V, Edwards, H & Foster, D

2017, 'Patient-centred care: a call to action for wound management', Journal of wound care,
vol. 26, no. 11, p. 662.

Milne, J 2016, 'The challenge of providing cost-effective wound care', Wounds U K, vol. 12,
no. 1, pp. 52-57.

Rondas, AA, Schols, JM, Stobberingh, EE & Halfens, RJ 2015, 'Prevalence of chronic
wounds and structural quality indicators of chronic wound care in Dutch nursing homes',
International Wound Journal, vol. 12, no. 6, pp. 630-635.

Shankar, R 2009, Process improvement using six sigma: a DMAIC guide, ASQ Quality Press.

Teehan, R & Tucker, W 2010, 'A simplified lean method to capture customer voice',
International Journal of Quality and Service Sciences, vol. 2, no. 2, pp. 175-188.

12