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Department of Emergency MedicineUniversity of North Carolina at Chapel Hill
The Patient Experience as an Indicator of Quality
Seth Glickman, MD, MBA
Assistant Professor of Emergency Medicine
University of North Carolina
Assistant Research Professor
Duke University Fuqua School of Business
•
Research funding–
Robert Wood Johnson Foundation
–
American Heart Association
–
National Institutes of Health Center for Research Resources
•
Co‐Founder, Tellus LLC
Disclosures
•
Historical context
•
Link to quality–
Clinical processes
–
Outcomes
–
Financial
•
Implications for quality management
Agenda
“It is futile to argue about the validity of patient
satisfaction as a measure of quality. Whatever its
strengths and limitations as an indicator of
quality, information about patient satisfaction
should be as indispensable to assessments of
quality as to the design and management of
health care systems.”
Structure‐Process‐Outcomes
Donabedian A, Quality of Medical Care, Milbank Quarterly, 1966
“I have been asked to answer the question ‘Has the measurement of patient
satisfaction improved the quality of care?’ The honest answer is: we do not know. A review of the literature yields no
evidence!”
Does the measurement of patient satisfaction improve care?
Vuori H. Quality Assurance in Health Care, Vol. 3, No. 3, pp. 183-189, 1991.
•
Key Quality Domains
–Clinical Process (20%)–Patient Experience [HCAHPS]
(30%)
–Efficiency (20%)–Outcomes (30%)
VBP weighting starting in 2014
How are we doing?
Jha A et al., NEJM, 2007
63.0% gave hospital high global rating
Patient satisfaction and clinical processes
Jha A et al., NEJM, 2007
Does patient global rating of care reflect technical quality of care?
Chang et al., Ann Intern Med, 2006
Or does global rating of care have more to do with provider communication?
Chang et al., Ann Intern Med, 2006
Patient satisfaction and AMI care quality
Glickman et al. Circ Cardiovasc Qual Outcomes, 2010.
Glickman et al. Circ Cardiovasc Qual Outcomes, 2010.
Predictors of satisfaction
Glickman et al. Circ Cardiovasc Qual Outcomes, 2010.
Patients can differentiate between personal vs. aesthetic aspects of their care
Personal
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Skill of nurses and
physicians
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Attention paid to personal
or special needs
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Time physician spent with
you
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Staff efforts to include you
in decisions
Aesthetic
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Room temperature and
décor
•
Quality and temperature of
food
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Waiting time for tests and
treatments
•
Speed of discharge process
Glickman et al. Circ Cardiovasc Qual Outcomes, 2010.
Variation in 30‐day hospital readmission rates
Jencks et al. N Engl J Med, 2009
Interquartile improvements in patient satisfaction scores and 30-day readmission rates
Glickman et al., American Journal Managed Care, 2010
Glickman et al., American Journal Managed Care, 2010.
What are the predictors of overall patient satisfaction?
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Individual patients may not always observe technical elements of care
–
E.g. Elderly
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Environments where patients “sense good”
things are happening are more likely to deliver high
quality, evidence‐based care
–
Particularly hospitals, health plans
•
These measures are complements, not substitutes
So what’s the relationship between patient satisfaction and quality?
Least
SatisfiedMost
satisfiedDifference
ED visits 17.6 14.3 −1.0 (−2.1 to 0.1)
Inpatient Admissions 10.7 11.5 +1.0 (0.2 to 1.9)
Total health
spending, mean$4646 $4729 +8.8% (1.6 to 16.6)
Prescription drug
spending, mean$1005 $1142 +9.1% (2.3 to 16.4)
Health care utilization by patient satisfaction quartile
Fenton et al, Arch Intern Med, 2012.
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Patient satisfaction scores factored into how nearly a quarter of physicians are paid
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Paying doctors to keep patients happy gives them a reason to acquiesce to patient demands
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Linking bonus pay to patient satisfaction could cause physicians to be more selective in who
they see
Are we creating the wrong incentives?
Center for Studying Health System Change, 2009.
Hospitals Aren’t HotelsBy THERESA BROWNPublished: March 14, 2012
“To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care.”
Hospitals turn to Disney for patient satisfaction advice
When the XXXX Hospital discovered in 2009 that it had some of the most dissatisfied patients in the country, it turned to an unlikely source for help --
Mickey Mouse and company.
2 years and about $200,000 in consulting fees to The Walt Disney
Co. later, work areas are now "back stage" and "front stage" zones. Many staff are "cast members," and new visitors to the 200-bed facility are met by a ukulele-playing greeter in Jungle Book-esque safari gear.
Patient satisfaction? It has moved up to the 80th percentile of all children's hospitals nationally, and patient volumes are up by almost half, said XXXX, the hospital's assistant administrator.
Sep 22, 2011
Management
Financial and operational performance
Clinical measures
Patient satisfaction
Patient safety indicators
CultureEmployeesOperationsTeamwork
Functional outcomes
30-day readmissionInpatient and
30-day mortality
Structure
Process
Outcomes
•
Manage to the metric or the patient experience?
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Benefits and limitations of benchmarking
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Create appropriate incentives
What are implications for hospital management?
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Patient satisfaction is a key determinant of quality
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Growing link to patient reported experience and outcomes but we need
better measures
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Managing the patient experience should be an important goal for hospitals!
Conclusions
Questions/Comments?
Memorial Sloan-Kettering Head Chef Pnina Peled created a lemon Alfredo pizza for a cancer patient.
What's on the MenuExamples of how Rex Healthcare in Raleigh, N.C., overhauled its menu in 2009.Old menu: Eggs, bacon, French toast, one pancake optionNew menu: Grilled portabella mushrooms topped with scrambled eggs, feta cheese and spinach. Four types of pancakes: blueberry, whole grain, buttermilk and banana nut. Grilled peaches with a splash of balsamic.Old menu: Fried or baked fish.New menu: Lime and ginger glazed salmon. Tilapia en papillote (tilapia filets with snipped green beans, lemon, capers, fresh oregano and white wine wrapped in paper and baked).Source: Jim McGrody, Rex Healthcare
New Hospital Cuisine: Dishes Made to OrderThe Wall Street Journal, Feb 21, 2012
Patient satisfaction and patient safety indicators
Decubitus ulcer Respiratory failure
R2 P‐value R2 P‐value
Would recommend
hospital‐0.28 <0.0001 ‐0.46 <0.001
Communication with
doctors‐0.17 0.005 ‐0.30 0.06
Communication with
nurses‐0.34 <0.001 ‐0.36 0.01
Clean and quiet
environment‐0.23 <0.0001 ‐0.14 0.34
Responsiveness of staff ‐0.35 <0.0001 ‐0.44 <0.001
Isaac et al, Health Services Research, 2010.
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Objective: To determine whether patient satisfaction is associated with
1)
adherence to practice guidelines for acute myocardial infraction
2)
outcomes (in‐hospital mortality) for acute myocardial infarction (AMI)
3)
identify the key drivers of patient satisfaction
Does patient satisfaction data provide valid insights into patient outcomes?
• 6,467 AMI patients at 25 hospitals
participating in the CRUSADE ACS QI initiative from 2001‐2006
• Press Ganey satisfaction survey data for
3,562 AMI patients
• Multi‐variable logistic regression to look at
predictors of mortality
The Approach
Predictors of 30-day Readmission Rates
Glickman et al., American Journal Managed Care, 2010.
The Cost of Satisfaction
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Cohort study of patients responding to MEPS survey 2000‐2007
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Patient satisfaction with physician communication from Consumer Assessment of Health Plans Survey
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Listened carefully
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Explained things in a way easy understand
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Showed respect what had to say
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Spent enough time
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Association of satisfaction with health utilization and outcomes Fenton et al, Arch Intern Med, 2012.
Patient
satisfaction
quartile
Adjusted, HR Adjusted HR
(excludes those with
poorest health
1, Least satisfied 1 [Reference] 1 [Reference]
2 1.08 (0.88‐1.31) 1.17 (0.89‐1.55)
3 1.02 (0.83‐1.26) 1.16 (0.87‐1.53)
4, Most satisfied 1.26 (1.05‐1.53)* 1.44 (1.10‐1.88)*
Mortality by patient satisfaction quartile
Fenton et al, Arch Intern Med, 2012.
* p< 0.05
Who is in charge of patient satisfaction at your hospital?
Health Management Academy, 2012
Biggest challenges in measuring patient satisfaction
Health Management Academy, 2012
Lee F. If Disney Ran Your Hospital. 2004.
Patient satisfaction and financial performance?
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Consumers–
Modest effect (at‐best) in previous studies
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Value opinions of friends and family
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Few patients even aware of information
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Hospitals–
Stimulation of QI activity in hospitals
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New York State Cardiac Surgery Reporting System
(NYS CSRS)
How will consumers and hospitals use this information?
Too much care?
Sirovich
et al, Arch Intern Med, 2011
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The Chest Pain Choice Decision Aid
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Decision aid vs
usual care for work‐up of low risk chest pain in the ER
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Higher engagement (patient involvement scores 26.6 versus 7.0)
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Lower
resource
utilization
(admission rate 58 versus 77%)
–
Higher
patient satisfaction (strongly
agree
61 versus 40%)
Does higher utilization necessarily mean higher patient satisfaction?
Hess et al, Circ Cardiosc
Qual
Outcomes, 2012
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Use best scientific evidence available
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Measure things for which respondent is best source of information
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Incorporate stakeholder input during development
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Develop reports in tandem with survey development
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Provide technical assistance to users
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Place products in public domain
Principles of HCAHPS development
Goldstein et al, Health Services Research, 2005.
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27 items –
18 substantive, 4 screener, 5 demographic
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Eligibility: >18, non‐psychiatric, overnight stay•
4 approved methods – mail, telephone, mail
w/ telephone, IVR•
48hours – 42 days after discharge
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Goal of 300 surveys per 4 quarters•
6 composite measures, 2 global, 2 standalone–
Doctors, nurses, responsiveness, pain
management, discharge, medications
Current HCAHPS survey instrument
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Patients lack scientific knowledge
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Patients' physical or mental states may impede objective judgments
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Patient satisfaction cannot be measured in a way that yields useful results
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Patients are often reluctant to disclose what they really think
Historic challenges to using patient satisfaction data
