Welcome to Value Based Quality and Safety. This is lecture d, Patient Experience. This lecture exam and tell the patient experience is defined in measured and how it is critical to value based quality, and safety The objectives for this lecture, patient experience are to understand and define what patient experience is. Describe how patient experience dictates quality. State the factors identified as key to a positive patient experience. Learn what the HCAHPs survey measures and recognize how HCAHPs are linked to hospital reimbursement. Traditionally, healthcare in the US has not revolved around meeting the needs of the patient. Emphasis and input has typically been elicited only from healthcare providers, physicians, nurses, etc. Inpatient services and physician practices are organized around specialties. Meeting the needs of each particular specialty, like a group of cardiologists and all the services they might require. But not meeting the needs of the patients who's needs go beyond just the cardiology services, we need to move away from this. An important starting point in understanding the connection between quality and the patient's experience is defining what we mean by patient experience. The Beryl Institute's definition is the sum of all interactions shared by an organization's culture that influences patients's perceptions across the continuum of care. They also said that critical to understanding and applying this definition is a broader explanation of it's key elements, interactions, culture, perceptions and continuum of care. What's unique about this definition is that need to include these key elements in any discussions about patient experience. It has the potential to drive patient-centered decisions and encourage a more integrated, quality experience. It is important that healthcare organizations develop and implement a defined process by which to engage both the patient, and the caregiver. In the past, healthcare's major focus was treatment, but there has been a paradigm shift that in addition to treatment also includes a focus on healing and a commitment to the patient and what matters most to him or her. The Institute of Medicine report crossing the quality chasm defined patient-centered care as care that is respectful of and responsive to individual patient preferences, needs and values and that ensures that patient values guide all clinical decisions. The greatest challenges will be to understand what patients want. What their preferences and values are, and to engage them routinely in decision-making. The new models of value-based care put a priority on the delivery of patient-centered care and healthcare provider's ability to deliver patient-centered care will effect how well they will manage with these new care models. Patients who are more engaged with their care are more committed to following the recommended treatment plans and are more likely to have positive outcomes. Measures of patient experience are increasingly included as a key measure of quality, as a part of value-based care. The National Quality Strategy includes measures of patient experience as a key element, which in turn has been adopted by CMS for clinical quality measure reporting. Even though patient experience is increasingly used as a quality metric, patients themselves are not looking at experience of care when making choices about their healthcare provider. Less than 10% of those responding in 2004 said, they used quality information when choosing their hospital or doctor. 11 years later, only 4% of respondents stated they used quality information when choosing hospitals. 6% in the same survey said, they used quality information when choosing their doctors. Doyle and colleagues found a positive association between patient experience and both clinical effectiveness, and patient safety. Other studies have found similar results. The study by Doyle et al which summarized evidence from 55 studies stated that the data indicates consistent positive associations between patient experience, patient's safety and clinical effectiveness for a wide range of disease areas, settings, outcome measure and study designs. It demonstrates positive associations between patient experience and self-rated, physical health and mental health and objectively measure health outcomes. Ulcer disease, hypertension, breast cancer, survival one year after discharge and in patient mortality for myocardial infarction. Adherence to recommended clinical practice and medication, preventive care, such as health promoting behavior, use of screening services and immunization. And resource use, such as hospitalization, length of stay and primary care visits. There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Public reporting is important for healthcare consumers to obtain comparative data on costs, outcomes and patient satisfaction. Reporting also holds providers accountable for their interactions with and perceptions by patients. Public data is an important resource for clinicians and hospitals to improve performance. For over 20 years, consumers have been able to compare health insurance plans using the publicly reported Healthcare Effectiveness Data and Information Set or HEDIS. Public reporting is one of the ten core set of principles guiding the national quality strategy. AHRQ developed the Consumer Assessment of Healthcare Providers and systems program or CAHPS. CMS requires hospitals to report patient experience information using HCAHPS in order to qualify fore medicare payments. The federal government also established the Patient-Centered Outcomes Research Institute, (PCORI), which expands the work of AHRQ and NIH to assist all stakeholders, patients, clinicians and policy makers in making informed healthcare decisions. The ACA requires that the priorities for PCORI align with the National Quality Strategy and that consumer input influence all phases of sponsored research. We have established the relationship between patients reported experiences and the quality of clinical care. We now turn our attention to expanding on and learning what really matters during the patient experience. According to England and Robert et al, this list indicates the issues that matters most to patients and their encounters with the healthcare system. Another paper by Tunnison and colleagues expands this list. These researchers found six common patient appraisal criteria. Some of which clearly overlap with the list on the screen. Their criteria were relevance, quality of life, quality of care, ethics and safety, information and communication and involvement. The Patient and Family- Centered Care or PFCC movement urges clinicians to incorporate patient preferences, values and strategy for self-management for all patient. To achieve this, the principles of PFCC serve as a reliable guide. These principles include respect and dignity, practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care. Information sharing, communicate complete and unbiased information. Participation, patients and families should participate in care and decision-making at the level they choose. Collaboration, patients and families are included on an institution wide basis and healthcare leaders collaborate with patients and families in policy and program development, implementation and evaluation. This chart shows the differences between expectation and reality, as a typical patient moves through the hospital. Patients usually arrive scared and worried, and they expect clinical staff to be reassuring during their stay. They expect to have their needs met and their concerns, and complaints listened to. But frequently, the staff are business like or unresponsive, the hospital room is noisy and stressful and the overall experience is unsatisfactory. It points out the importance of managing expectations and closing the gap between the hope that patients have when they come into the hospital, and the realization they are stuck with when they leave. We certainly have work to do. CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. CAHPS includes a group of surveys to obtain data from healthcare consumers on their experiences with services in different settings. For example, settings would include hospitals, home health and hospice as well as individuals and groups participating in CMS initiatives, such as ACOs. The agency for healthcare research and quality oversees CAHPS survey development and approval by the CAHPS consortium. According to AHRQ, all CAHPS surveys undergo a rigorous development process to confirm the validity and reliability of the surveys and insure that survey results are comparable across users. Health plans and individual providers can use specific CAHPS questions to identify areas of care that are strong, as well as those that need improvement. Many private consultants, such as Prescany combine the required CAHPS questions with other patient-centered questions to provide a more comprehensive view of the overall patient experience. Note however, that the patient's experience of care is included in all of these surveys. These questions represent areas that both patients and providers have indicated are determinants of a good provider visit. These areas include patient centeredness, timeliness, accessibility and communication. Interestingly, CAHPS is not a satisfaction survey. It measures the patient's descriptions of staff behaviors. The survey contains 32 questions, including 21 patient perspectives on care in addition to the 4 screener and 7 demographic items. The screener questions and demographic questions are used to adjust the mix or patients across hospitals, and for analytical purposes as the CAHPS's website explains. While the terms are sometimes used interchangeably, patient experience is quite different from patient satisfaction. Patient satisfaction can vary due to differing expectations. That is patients who have similar experiences, but different expectations can have very different levels of satisfaction. CAHPS surveys focus on patient experience of care. The surveys do as respondents to provide overall ratings. For example, to rate their doctor on a zero to ten scale, but their primary focus is on asking patients to report on their experiences with specific aspects of care in order to provide information that is not biased by different expectations. For example, respondents are asked whether or how often specific events or behaviors that are indicators of healthcare quality occurred. Reports about events and behaviors are more understandable, unambiguous, actionable and objective then general ratings. The use of HCAPS, which is the hospital-based survey has been incentivized by the Inpatient Prospective Payment System since 2007 and is also included in the value based incentives of the Affordable Care Act. According to CMS, CAHPS surveys are an essential part of there efforts to improve healthcare here in the US. The CMS website explains that some CAHPS surveys are used in value-based purchasing or pay for performance initiatives. These initiatives represent a change in the way CMS pays for services. Instead of only paying for the number of services provided, CMS also pays for providing high quality services. The quality of services is measured clinically, administratively and through the use of patient experience of care surveys. This concludes lecture d, patient experience. Patient experience always import to the patient and tangentially to the healthcare provider has moved center stage. The patient experience is now considered a critical element of the provision of healthcare. Research has shown that a positive patient experience is consistently associated with better care outcomes. A positive patient experience is value adding throughout the value chain. It is key in adding value to any product produced. The HCAHP survey was discussed and is used, as a standardized survey instrument to gather comparable patient experience information nationwide. Linking the patient experience to financial reimbursement, reinforces the importance of the patient experience and pushes health care organizations toward better quality.
