Overview of Patient Experience Definitions and Measurement Tools

Overview Of Patient exPerience: Definitions anD MeasureMent tools

Darien T. KaDens, PhD, MBa, DirecTOr Of healThcare research, sODexO

rachel PerMuTh, PhD, MsPh, naTiOnal research DirecTOr, innOvaTiOns 2 sOluTiOns, sODexO

TaylOr lauricella, PhD canDiDaTe, inDusTrial anD OrganizaTiOnal PsychOlOgy, sODexO research fellOw

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The information and concepts contained in this document are the proprietary property of Sodexo. As such, they cannot be reproduced or utilized without permission.© 2015

In the healthcare system worldwide, there has been a shift from a traditional, disease-centered approach toward a more contemporary, holistic patient-centered care model. As more hospitals convert to this patient-centered model, the standard for defining and measuring quality services has evolved to include a construct known as “patient experience.” In fact, Patient experience is now considered one of the three pillars of quality in healthcare, along with clinical effectiveness and patient safety.1 Despite its importance and widespread acceptance, Patient Experience as a construct is not standardized, with many existing definitions and measurement instruments. Therefore, this publication will provide an overview of patient experience, how it is measured, and how to achieve it optimally within the healthcare setting. Sodexo’s definition of Patient Experience will also be explored.

Defining Patient-CentereD Care

in a traditional disease-centered approach, the provider makes all decisions regarding the health of the patient, using empirical evidence and data. this approach is usually reactive, occurring in response to a patient developing an illness.2 in patient-centered care, however, the provider actively works with and engages the patient and his/her family to identify and fulfill the full spectrum of patient needs.3 this process is accomplished through ongoing patient feedback, practice-based learning and comprehensive care, which gives patients a smooth transition as they progress through all aspects of care.4

according to researchers Morgan and Yoder, there are four key attributes of patient-centered care: holistic care, individualized care, respectful care and empowering care (see figure 1).5,6 Holistic care refers to valuing the whole patient by meeting his/her physical and psychological needs, while also recognizing his/her values and beliefs. Individualized care occurs when healthcare providers take into account a patient’s unique needs and preferences. Respectful care refers to recognizing the patient as an active health consumer, providing a patient with options and listening to the patient’s wishes. Empowering care occurs when healthcare providers encourage autonomy and facilitate patient participation in decision-making.5,6

figure 1. attributes of Patient-Centered Care

Empowering Care

Holistic Care

Respectful CareIndividualized Care

PaTIEnT-CEnTEREd

CaRE

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There are a number of benefits of the patient-centered model over a disease-based approach. One benefit is that patients and families feel they have a voice throughout the healthcare process. this helps to establish trust between the provider, the patient and the family, and leads to higher levels of satisfaction with healthcare services.6

in addition, research shows that a patient-centered model results in better health outcomes than a disease-centered model. for example, one study found that patients who experienced more patient-centered care during their stay required fewer visits to specialty care clinics, fewer hospitalizations, and fewer laboratory and diagnostic tests after being released.7 similarly, a recent meta-analysis of 29 studies found that patient-centered care was related to increases in emotional well-being, improvements in physical symptoms, engagement in healthy behaviors, and a reduction in hospital visits.5

whaT is Patient exPerience?

the concept of Patient Experience has emerged as a result of the shift toward a patient-centered care model. from a business perspective, hospitals that focus on all aspects of the patient’s experience are more likely to see improvements in their patient satisfaction survey data and HCaHPs. Because HCaHPs scores are publically available, hospitals scoring high on them can attract more patients, providers and payers.8 in order to realize these outcomes, however, it is essential that hospitals understand what Patient Experience is, how to improve it, and how to measure it.

Patient Experience is widely assessed among patient-centered healthcare systems. However, although Patient Experience has been extensively studied and measured, there is not one standard definition. Rather, there are a number of definitions and dimensions covered within this construct. the variation among them is often based on the healthcare system and/or the measurement tool used.

Jason a. Wolf, Ph.D., executive Director of the Beryl institute, defines Patient Experience as “a patient’s cumulative evaluation of the journey they have with [the healthcare system], starting when they first need [you], and based on their clinical and emotional interactions, which are shaped by your people, processes and your physical setting.”9 Meanwhile, Dr. suzanne shale – oxford university fellow and consultant in the fields of Patient Experience and healthcare ethics – describes how Patient Experience refers to “…reducing suffering and reducing anxiety [to the patient] across the entire continuum of care, from first phone call to discharge.”10

in research commissioned by the uK’s national institute for Health research (niHr), Doyle et al. hypothesized that Patient Experience can be conceptualized through its various dimensions, which differ across definitions. For example, one perspective of patient experience defines it as the combination of the relational and functional aspects of care (see figure 2). the relational aspect refers to the interpersonal pieces. this includes emotional and psychological support, as well as treating patients with compassion, dignity and respect. other interpersonal aspects involve enabling self-care, giving families a voice in decision-making, and providing the patient with clear, transparent information. Meanwhile, functional aspects refer to the basic conditions of care. these include effective and timely treatment, providing the patient with a safe, comfortable and clean environment, and coordinating smooth transitions and continuity between healthcare teams.11

figure 2. relational and functional aspects of Patient Experience

Meanwhile, according to researchers Wolf et al., another way to conceptualize patient experience is to understand whether the psychological needs of the patient are being met. The first psychological need is confidence; meaning, whether the patient trusts the healthcare system. the second, integrity, describes whether a patient is treated fairly. the third, pride, alludes to whether the patient feels positively about their interactions within the healthcare system. the last, passion, describes whether the healthcare system has invested in the patient and the patient will return to the same system in the future, if needed. When all four needs are met, the ideal Patient Experience has occurred.10,12

according to the Beryl institute, Patient Experience is defined as “…the sum of all interactions, shaped by an organization’s culture that influence patient perceptions across the continuum of care.” 9,13,14 interactions refer to the interface between the patient and the employees, policies, processes and healthcare environment. the culture refers to the vision and values of the organization. Perceptions include what is understood and remembered by patients. Continuum of care includes the delivery of care before, during and after the patient’s stay.

relaTiOnal asPecTs

Compassion

Dignity

respect

self-care

Voice

transparency

funcTiOnal asPecTs

Effective and Timely treatment

safe environment

Clean environment

Comfort

smooth transitions

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Sodexo’s definition of Patient Experience reflects this emphasis on the continuum of care (see figure 3). the Patient Experience begins during pre-admission with tasks like scheduling necessary tests and confirming the appointment, and continues post-discharge with follow-up and a reminder for future appointments. During the patient’s stay, however, treatment is only one aspect of their care – they might also be assisted with things like pet care, running errands, or arranging lodging and transportation for visitors.

in fact, sodexo recognizes that the ideal Patient experience is increasingly being defined by non-clinical elements, such as convenience, customer service and staff attitude. in fact, more than 80% of the time a patient spends in the hospital is not related to direct care. Patients who report any problem with their room or hospital staff rate their overall experience 39% lower than patients with no problems. therefore, a more well-designed Patient Experience alone will not achieve success. Creating a truly engaged workforce that remains consistent over time is also critical to delivering lasting change.

figure 3. Sodexo’s Definition of the Patient Experience

THE PatiEnt ExPEriEncE

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In sum, although there is no standard definition for Patient Experience, there are several themes that are touched upon across these various definitions. Patient experience encompasses a patient’s entire journey through the healthcare system, with an emphasis on smooth transitions as the patient progresses. the psychosocial needs of the patient hold equal importance to the quality of the environment and the quality of care. Most importantly, all definitions of Patient Experience reflect a patient-centered care approach. next, we will examine the relationship between Patient Experience and other constructs related to patient care.

hOw DOes Patient exPerience Differ frOM OTher relaTeD cOnsTrucTs?

Patient Experience vs. Patient SatisfactionPatient Experience and patient satisfaction are often used interchangeably – but many would argue that the two are very different. a dominant perspective is that patient satisfaction is a subset of Patient experience (see figure 4). Patient satisfaction refers to a patient’s (positive) perceptions of care. Patient Experience, on the other hand, encompasses both having a happy patient and ensuring high-quality care and service outcomes.13,15 furthermore, Patient Experience encompasses the dynamics of the relationship between a patient and the healthcare worker. it also emphasizes engagement, both of the patient and the employees; whereas patient satisfaction covers the static perspective of the patient.16

figure 4. Patient satisfaction is a subset of Patient Experience

Patient exPerience vs. PaTienT QualiTy Of life

it is not always apparent how Patient Experience differs from patient quality of life, as they both emphasize the lifestyle and psychosocial needs of the patient. Patient quality of life, however, typically refers to a specific subset of patients, whereas patient experience is much broader. Specifically, patient quality of life is typically used in context of patients suffering from a major illness, patients who recently underwent a surgical operation, and/or patients who are nearing the end of their lives. the goal of patient quality of life is also very specific: to relieve suffering.17 Patient Experience, on the other hand, encompasses patients in varying stages of illness with an emphasis both on psychosocial needs and providing the best care possible.

Patient exPerience

� Detailed experience of healthcare service

� Patient engagement

� Engagement of staff

Positive patient perceptions

PaTienT saTisfacTiOn

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Sodexo’s definition of patient quality of life, however, is more closely aligned with Patient Experience and quality of care. sodexo’s six Dimensions of Quality of life are described in figure 5.

figure 5. sodexo’s six Dimensions of Quality of life

However, Quality of Life issues differ, depending on the environment. When examining Quality of life among patients, the dimensions of most relevance would include:

� Physical environment: for example, appropriate temperature, access to nature, and quality furniture in patient rooms.

� social interaction: this could include the provision of comfortable visiting areas and facilitating positive interactions between staff and patients.

� ease and efficiency: for example, reducing wait times or streamlining communication between healthcare staff and patients.

� health and well-Being: this could include the provision of nutritious and healthy patient meals, and advice on nutrition and lifestyle.

in recent research conducted by sodexo’s Quality of life institute, 90% of hospital leaders strongly agreed that they place a high level of importance on improving quality of life in their organization.18 this is explained in part by the nature of a healthcare organization’s activities, which aim to directly improve the Quality of Life of their end-user: the patient.

the survey also revealed that hospital leaders believe that the concept of Quality of Life has shifted dramatically, and will continue to undergo changes in the coming years. according to one hospital director in france, “we must always reevaluate Quality of life for our patients. we don’t address this topic as we did 20 years ago, and 20 years from now it will be different again. Quality of Life is a topic that never stops

evolving.”

hOw is Patient exPerience MeasureD?

there are a number of existing measures that can be used to measure Patient Experience. One common measure is the hcahPs (hospital consumer assessment of healthcare Providers and systems) survey. the HCaHPs was created in order to have a standardized measure of Patient Experience that can be used to make comparisons across various hospitals. the survey contains 32 questions and covers eight key dimensions (see figure 6).1

In addition to effectively measuring Patient Experience in these areas, the HCaHPs survey also accomplishes three other important goals. First, it allows for objective and meaningful comparisons across healthcare systems. second, the survey results are reported publicly, which incentivizes providing quality healthcare. third, the public reporting enhances accountability of hospitals. in order for hospitals to use this survey and participate in public reporting, they must meet a number of program requirements, including HCaHPs training.1

Press ganey is the largest hcahPs administrator in the u.s.19 However, the company believes that to advance the Patient Experience, providers must obtain a more in-depth understanding of patient needs and address targeted opportunities within patient populations. With that in mind, Press Ganey works with providers across the care continuum to collect feedback through census-based survey instruments containing additional questions around perception of care. the robust data sets and shortened improvement cycles allow organizations to act more rapidly on patient insights, and have opportunities to validate, monitor, course-correct and enhance initiatives.

as a result of extensive research and analysis, combined with nearly 50 years of experience, Sodexo has identified 6 dimensions essential to Quality of Life.

Social Interaction – Factors that strengthen bonds among individuals and facilitate access to activities or events.

Personal Growth – Everything that allows an individual to learn and make progress.

Ease and Efficiency – Ability to devote your full attention to the task at hand and carry it out with ease, efficiency and minimal interruption.

Recognition – Factors that contribute to an individual feeling truly valued and appreciated.

Physical Environment – Factors that contribute to a person’s comfort and sense of well-being.

Health and Well-Being – Promoting a healthy lifestyle through a well-balanced diet and physical activity.

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another instrument used to study patient experience is the Picker Patient experience Questionnaire-15 (PPe-15). the PPe-15 is a 15-item measure that was validated using data collected from patients in the united Kingdom, Germany, sweden, switzerland and the united states. eight dimensions are covered within this instrument (see figure 6). the PPe-15 is highly reliable and is often used in research settings.20

figure 6. Comparison of HCaHPs and the PPe-15

achieving OPTiMal Patient exPerience

Regardless of the definition or instrument utilized, achieving optimal Patient experience is of the utmost importance for healthcare systems. there are a number of strategies an organization can employ to optimize Patient Experience (see Figure 7). According to Planetree, the first step is fostering a strong culture of patient-centered care. in the most extreme scenario, this process may involve a cultural transformation of the healthcare organization, which can be achieved through organizational assessments, strategic planning, and implementation of new systems, processes and policies. it is also important to engage current employees and develop an effective leadership team. this step reinforces the patient-centered culture among staff and creates a supportive, positive work environment for employees. the next step is to promote patient activation, which occurs when patients are given access to resources and information that enable them to participate in their care process. lastly, it is critical to measure the performance of the healthcare system through assessments.21 receiving feedback from patients is an invaluable tool that allows healthcare providers to understand which areas they are excelling in and which areas need future improvement.

figure 7. the Planetree approach

sODexO’s recOMMenDaTiOns fOr fuTure OPeraTiOnalizaTiOn Of Patient exPerience

Planetree’s recommendations above capture four essential steps required to achieve optimal Patient Experience. However, sodexo recognizes that the ideal Patient Experience is increasingly being defined by non-clinical elements through employees at all levels of the organization. as previously mentioned, more than 80% of the time a patient spends in the hospital is not related to direct care.

With this in mind, it is imperative that training be provided not only for physicians and nurses, but also for frontline workers, including environmental services staff and food service workers. this training should educate employees on specific, expected behaviors, and should be experiential so that employees can better understand how patients feel and practice behaviors that contribute to an improved Patient Experience. sodexo’s healthcare employees take part in empathy awareness training and receive extensive Cares behavioral training – focusing on compassion, accountability, respect, enthusiasm and service.

furthermore, communication about the role frontline workers play in creating the optimal patient experience should occur at all levels of the organization, with specific emphasis on the outcomes that can be achieved for patients (higher satisfaction and better health outcomes), employees (greater job satisfaction and engagement), and the organization (greater market share).

in sum, a more well-designed Patient Experience alone will not achieve success. Creating a truly engaged workforce is also critical to delivering lasting change.

DiMensiOns Of hcahPs Dimensions of the PPe-15

� Communication with nurses

� Communication with Doctors

� responsiveness of Hospital Staff

� Pain Management

� Communication about Medicines

� Hospital Cleanliness and Quietness

� Discharge information

� overall rating of Hospital

� information and education

� Physical Comfort

� emotional support

� respect for Patient Preferences

� Coordination of Care

� involvement of family and friends

� Continuity and transition

� Continuity and transition

PPatient Activation

PPerformance Improvement

PLeadership development

PStaff Engagement

4 sTePs TO OPTiMize Patient exPerience

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references

[1] HCAHPS: Hospital Consumer Assessment of Healthcare Providers and systems. (2015). about the survey. retrieved from http://www.hcahpsonline.org/home.aspx

[2] stanton, M. W. (2002). expanding patient-centered care to empower patients and assist providers.

[3] Shaller, D. (2007). Patient-centered care: What does it take? Retrieved from http://www.commonwealthfund.org/usr_doc/shaller_patient-centeredcarewhatdoesittake_1067.pdf?section=4039

[4] Davis, K., schoenbaum, s. C., & aidet, a. M. (2005). a 2020 vision of patient-centered primary care. Journal of General Internal Medicine, 20, 953-957

[5] McMillan, s. s., Kendall, e., sav, a., King, M. a., Whitty, J. a., Kelly, f., & Wheeler, a. J. (2013). Patient-centered approaches to health care: a systematic review of randomized controlled trials. Medical Care Research and Review.

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[7] Bertakis, K. D., & azari, r. (2011). Patient-centered care is associated with decreased health care utilization. The Journal of the American Board of Family Medicine, 24, 229-239.

[8] institute for Healthcare improvement. (n.d.). the Patient Experience: Overview. Retrieved from http://www.ihi.org/education/inPersontraining/thepatientexperience/Pages/default.aspx

[9] Wolf, J. a. (2014). Patient Experience, satisfaction not one and the same. Retrieved from http://www.hospitalimpact.org/index.php/2014/07/24/patient_satisfaction_experience_not_one

[10] shale, s. (2003). Patient Experience as an indicator of clinical quality in emergency care. Clinical Governance: An International Journal, 18, 285-292.

[11] Doyle, C., lennox, l., & Bell, D. (2013). a systematic review of evidence on the links between Patient Experience and clinical safety and effectiveness. BMJ Open, 3, 1-18.

[12] Wolf, J. a., niederhauser, V., Marshburn, D., & laVela, s. l. (2014). Defining Patient Experience. Patient Experience Journal, 1, 7-19.

[13] stempniak, M. (2013). the Patient Experience: Taking it to the next level. H & HN: Hospitals and Health Networks, 87, 41-47.

[14] The Beryl Institute. (n.d.). Defining the Patient Experience. Retrieved from http://www.theberylinstitute.org/?page=DefiningPatientExp.

[15] Grigsby, J. E. (2011). Patient satisfaction: Why it matters. Retrieved from http://www.nhfca.org/Presentations/Patient%20satisfaction_9.29.11.pdf

[16] Devkaran, s. (2014). Patient Experience is not patient satisfaction: Understanding the fundamental differences. Retrieved from http://www.isqua.org/docs/default-source/education-/isqua-webinar_november-2014_subashnie-devkaran.pdf?sfvrsn=0

[17] Patient Quality of life Coalition. (n.d). about PQlC. retrieved from http://patientqualityoflife.org/about-pqlc/

[18] sodexo institute for Quality of life. (2015). How leaders Value Quality of Life in Their Organization: the first international study. Retrieved from http://viewer.zmags.com/publication/a4f69838#/a4f69838/1

[19] Press Ganey. (2015). Patient Experience solutions. retrieved from http://www.pressganey.com/solutions/patient-experience

[20] Jenkinson, C., Coulter, a., & Bruster, s. (2002). the Picker Patient Experience Questionnaire: development and validation using data from in-patient surveys in five countries. International Journal for Quality in Health Care, 14, 353-358.

[21] Planetree. (2014). Approach. Retrieved from http://planetree.org/approach/