Measuring the Patients’ Experience with Care Disclosure Project Discussion Forum July 12, 2007 Dale Shaller, MPA Shaller Consulting Managing Director,

Measuring the Patients’ Measuring the Patients’ Experience with CareExperience with Care

Disclosure Project Discussion ForumDisclosure Project Discussion Forum

July 12, 2007July 12, 2007

Dale Shaller, MPADale Shaller, MPA

Shaller Shaller ConsultingConsulting

Managing Director, National CAHPS Benchmarking DatabaseManaging Director, National CAHPS Benchmarking Database

[email protected]@comcast.net

651-430-0759651-430-0759

Presentation OutlinePresentation Outline

What is the “patient experience with care”?What is the “patient experience with care”? Why is it important?Why is it important? How can it be measured?How can it be measured? What is the unique contribution of CAHPSWhat is the unique contribution of CAHPS®® to to

measuring the patient experience?measuring the patient experience? How is the nation’s health system performing on key How is the nation’s health system performing on key

CAHPS measures?CAHPS measures?

IOM’s 6 Aims for ImprovementIOM’s 6 Aims for Improvement

EquityEquity

EfficiencyEfficiency

TimelinessTimeliness

Patient-CenterednessPatient-Centeredness

EffectivenessEffectivenessSafetySafety

Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press: 2001.

IOM DefinitionIOM Definition

““Health care that establishes a Health care that establishes a partnership among practitioners, partnership among practitioners,

patients, and their familiespatients, and their families…to …to ensure that decisions ensure that decisions respect respect patients’ wants, needs, and patients’ wants, needs, and

preferencespreferences and that patients have the and that patients have the education and supporteducation and support they need to they need to make decisions and participatemake decisions and participate in in

their own care.”their own care.”Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: 2001.

Picker DimensionsPicker Dimensions Respect for patient values, preferencesRespect for patient values, preferences Coordination and integrationCoordination and integration Information, communication, educationInformation, communication, education Physical comfortPhysical comfort Emotional supportEmotional support Involvement of family and friendsInvolvement of family and friends Transition and continuityTransition and continuity Access to careAccess to care

Gerteis M, et al. Through the Patient’s Eyes. San Francisco: Jossey-Bass: 1993.

Patient experience is strongly Patient experience is strongly correlated with other key correlated with other key outcomesoutcomes Health Outcomes:Health Outcomes:

Patient adherencePatient adherence Process of care measuresProcess of care measures Clinical outcomesClinical outcomes

Business Outcomes:Business Outcomes: Patient loyaltyPatient loyalty Malpractice risk reductionMalpractice risk reduction Employee satisfactionEmployee satisfaction Financial performanceFinancial performance

Edgman-Levitan S., Shaller D. et al. The CAHPS Improvement Guide. Boston: Harvard Medical School: 2003.

Patients Who Experience Worse Hospital CarePatients Who Experience Worse Hospital CareAre More Likely to Report Chest Pain 12 Months Are More Likely to Report Chest Pain 12 Months

After AMIAfter AMI

22.8

37.537.6

54.5

0

25

50

75

100

Chest Pain Shortness of Breath

Better Care Worse Care

Fremont A, et al. Patient-Centered Processes of Care and Long-Term Outcomes of Myocardial Infarction. JGIM 16 (December 2001): 800-808.

Percent of patients with symptoms

Approaches to measuring Approaches to measuring patient experience with carepatient experience with care

Patient surveysPatient surveys Proprietary toolsProprietary tools Public domain instruments (CAHPS)Public domain instruments (CAHPS)

Focus groups and interviewsFocus groups and interviews WalkthroughsWalkthroughs ““Mystery shopping”: participant Mystery shopping”: participant

observation by trained informantsobservation by trained informants Web-based “convenience” reportingWeb-based “convenience” reporting

Caveat emptor: example of Caveat emptor: example of consumer “convenience” consumer “convenience” reportingreporting

The Evolution of CAHPSThe Evolution of CAHPS

““CAHPS” = CAHPS” = Consumer Assessment of Healthcare Consumer Assessment of Healthcare Providers and SystemsProviders and Systems

Most widely used survey tools for measuring the Most widely used survey tools for measuring the patient’s experience with care patient’s experience with care

CAHPS Consortium initiated and funded by AHRQ CAHPS Consortium initiated and funded by AHRQ since 1995:since 1995: CAHPS I: Focus on health plans and consumer choiceCAHPS I: Focus on health plans and consumer choice CAHPS II: Expansion of survey instrumentsCAHPS II: Expansion of survey instruments CAHPS III: New focus on QI and reporting CAHPS III: New focus on QI and reporting

applicationsapplications Current consortium members include: AHRQ, Current consortium members include: AHRQ,

CMS, AIR, RAND, Yale/Harvard, and WestatCMS, AIR, RAND, Yale/Harvard, and Westat

Expanding Suite of CAHPS Expanding Suite of CAHPS SurveysSurveys

HospitalsHospitals Dialysis FacilitiesDialysis Facilities Nursing HomesNursing Homes

Health PlansHealth Plans Group PracticesGroup Practices Individual CliniciansIndividual Clinicians Behavioral Health Behavioral Health

Organizations (ECHO)Organizations (ECHO) Home HealthHome Health

Facility CareFacility Care Ambulatory Ambulatory CareCare

Common CAHPS Design Common CAHPS Design PrinciplesPrinciples

Include reports Include reports andand ratings of ratings of experiences – not “satisfaction”experiences – not “satisfaction”

Standardization to enable valid Standardization to enable valid comparisons (through CAHPS Database)comparisons (through CAHPS Database)

Content based on evidence of what Content based on evidence of what patients want to know and for which patients want to know and for which they are the best or they are the best or onlyonly source of source of informationinformation

Question items and survey protocols Question items and survey protocols based on rigorous scientific based on rigorous scientific development and testing, as well as development and testing, as well as stakeholder inputstakeholder input

Common CAHPS Design Common CAHPS Design Principles (continued)Principles (continued)

A core set of question items with option A core set of question items with option to add from a bank of tested to add from a bank of tested supplemental questions:supplemental questions: Special populations (e.g., chronic Special populations (e.g., chronic

conditions, persons with mobility conditions, persons with mobility impairments)impairments)

Quality improvement applicationsQuality improvement applications Focus on development of reports as Focus on development of reports as

well as survey instrumentswell as survey instruments All CAHPS surveys and services are in All CAHPS surveys and services are in

the public domainthe public domain

CAHPS Health Plan SurveyCAHPS Health Plan Survey

Over 138 million Americans are enrolled Over 138 million Americans are enrolled in health plans that are assessed using in health plans that are assessed using CAHPSCAHPS

Major users:Major users: Federal purchasers: CMS, OPM, DoDFederal purchasers: CMS, OPM, DoD NCQA: Health plan accreditation NCQA: Health plan accreditation State Medicaid AgenciesState Medicaid Agencies Health plansHealth plans Employer coalitions (e.g., NBCH eValue8)Employer coalitions (e.g., NBCH eValue8)

Major Domains of CAHPSMajor Domains of CAHPSHealth Plan Survey 4.0Health Plan Survey 4.0

Access: getting needed careAccess: getting needed care Access: getting care quicklyAccess: getting care quickly Doctor communicationDoctor communication Health plan customer service, information, and Health plan customer service, information, and

paperworkpaperwork Global ratings (overall care, health plan, personal Global ratings (overall care, health plan, personal

doctor, specialist)doctor, specialist)

National CAHPS Benchmarking Database. 2006 CAHPS Health Plan Survey Chartbook. (October 2006)

CAHPS Hospital Survey (H-CAHPS Hospital Survey (H-CAHPS)CAHPS)

Nation’s first standardized survey of inpatient Nation’s first standardized survey of inpatient experiences with careexperiences with care

Endorsed by National Quality Forum in 2005Endorsed by National Quality Forum in 2005 Centers for Medicare and Medicaid (CMS):Centers for Medicare and Medicaid (CMS):

2007 H-CAHPS reporting tied to hospital payment 2007 H-CAHPS reporting tied to hospital payment increasesincreases

Public reporting in March 2008 Public reporting in March 2008

Dimensions Measured by H-Dimensions Measured by H-CAHPSCAHPS

Composites:Composites: Communication with doctorsCommunication with doctors Communication with nursesCommunication with nurses Communications about medicationsCommunications about medications Pain managementPain management Cleanliness and quiet of hospital environmentCleanliness and quiet of hospital environment Discharge informationDischarge information

Overall ratingOverall rating Willingness to recommendWillingness to recommend

77

56

66

69

19

28

27

25

23

17

27

23

16

15

9

8

6

54

58

77

0% 20% 40% 60% 80% 100%

Communication AboutMedications

Discharge information(yes/no)

Staff Responsiveness

Cleanliness and Quiet

Pain management

Nurse Communication

Doctor Communication

Always Usually Never

2006 H-CAHPS Composite Results2006 H-CAHPS Composite Results

National CAHPS Benchmarking Database. 2007 CAHPS Hospital Survey Chartbook. (May 2007)

CAHPS Clinician & Group CAHPS Clinician & Group SurveySurvey Adopted by AQA and submitted for Adopted by AQA and submitted for

endorsement by NQF endorsement by NQF Adult, pediatric, and specialty versionsAdult, pediatric, and specialty versions Core composites:Core composites:

Access: Getting appointments and care when Access: Getting appointments and care when neededneeded

Doctor communicationDoctor communication Office staff courtesy and helpfulnessOffice staff courtesy and helpfulness

Many supplemental items:Many supplemental items: Health promotion and educationHealth promotion and education Shared decision makingShared decision making QI itemsQI items Visit-specific questionsVisit-specific questions

Implementation Models for Implementation Models for CAHPS Clinician & Group SurveyCAHPS Clinician & Group Survey

Regional collaborativesRegional collaboratives BQI marketsBQI markets Aligning Forces marketsAligning Forces markets

Accreditation/certificationAccreditation/certification American Board of Medical SpecialtiesAmerican Board of Medical Specialties

National health plan consortiumNational health plan consortium CSS initiativeCSS initiative

Independent effortsIndependent efforts Health plansHealth plans Medical groupsMedical groups

Public Reporting of Survey Public Reporting of Survey MeasuresMeasures

Out of 211 “report cards” in AHRQ’s Report Card Out of 211 “report cards” in AHRQ’s Report Card Compendium:Compendium: 113 include patient experience measures113 include patient experience measures

69 health plan reports69 health plan reports 20 medical group/clinic reports 20 medical group/clinic reports 19 hospital reports19 hospital reports 3 nursing home reports3 nursing home reports 2 individual physician reports2 individual physician reports

http://www.talkingquality.gov/compendium/index.htmlhttp://www.talkingquality.gov/compendium/index.html