Beyond CAHPS—Measuring the Patient Experience Digitally and Why It Matters
Why Track the Patient Experience?
For every patient who expresses dissatisfaction or voices concern, there are nine or ten more who keep quiet.1 However, dissatisfied patients are often some of the most vocal. They are likely to tell at least 20 people about their experiences or go to an online review site.1
Why does this matter? Aside from the potential impact on a provider's reputation, patients who rate practitioners' bedside manner the worst are far more likely to bring a malpractice suit. In fact, providers whose patient satisfaction scores fall within the bottom third are 110 percent more likely to be sued when compared to their top performing peers.2
Patient satisfaction is consistently at the root of these claims. Multiple studies have found that it's poor communication or patients feeling like their doctor simply didn't care, not negligence, that is the primary driver of malpractice lawsuits. 2
Satisfied patients also equate to satisfied providers. It has been shown that practices with loyal patients have lower rates of physician turnover.1 With the average cost to replace a physician clocking in at more than $300,000 per practice, physician retention is more important than ever.1
These all-too-common scenarios can be avoided, or at least significantly reduced. When patient satisfaction is up, so is your bottom line. A recent report indicated that U.S. hospitals with top patient satisfaction scores gained net margins that were 50 percent higher than those that provided an average-to-poor patient experience.3 Additionally, patient satisfaction has been linked to better patient adherence to recommended treatment plans, which can improve health outcomes.3 Driving real-time patient feedback and improvement opportunities to administrators and providers is key to continual improvement and success in today's rapidly changing healthcare market.
The Problem with CAHPS® and Delayed ReportingWhile most providers were blue ribbon students in school, used to being "the best," most have never received real performance feedback. When asked about their experiences with federally mandated CAHPS® surveys, 90 percent surveyed reported that they had never received any feedback. Of the ten percent who had, more than half said CAHPS survey results weren't useful.
Not only are practitioners not seeing results data, but CAHPS surveys are costly, slow and yield poor patient response rates. Regulations placed upon survey vendors to administer CAHPS surveys require outdated staffing, function and administration, which in turn translates to higher costs for healthcare organizations and patients. The Centers for Medicare and Medicaid Services (CMS) still require patients to be surveyed using mailed paper surveys or live telephone interviews.4 Modern modalities such as SMS (text message) and email are prohibited for most CAHPS® surveys, despite a proven track record.
Data is also inadequate. Hospitals have to return just 300 patient surveys to CMS annually to satisfy HCAHPS® requirements, even if the hospital sees hundreds of thousands of patients.5 So few returned surveys is a red flag concerning statistical validity. CAHPS results may very well not be a representative snapshot of the patient experience and should be utilized with caution when drawing conclusions about individual physicians or the organization as a whole.
On top of that, CAHPS results are delayed. Many organizations simply run the surveys to "fill the square," but aren't seeing results until months later, and, therefore, not improving. To illustrate this, a hospital-owned outpatient group conducted a trial, electing to run CG-CAHPS surveys digitally over a 48- week period. The organization examined patients' perceptions of care—whether or not running the surveys resulted in improved scores. Nearly 10,000 patient surveys were completed during the observation period. The outcome? Other than accelerating global warming, the results regressed to a mean, less than 3 on a 5 scale, and stayed there. The positive slope was infinitesimal. No improvement occurred. Simply running surveys does not necessarily improve patients' perceptions of care.
Beyond CAHPS : The Value of Real-Time FeedbackAlternatively, when valid, timely feedback is easily accessible and driven to those closest to the problem or opportunity— in this case providers—patients' perceptions of care are improved.
A case study (See Figure 1) was conducted by a group of eight anesthesiologists who wrote a white paper in conjunction with the American Society of Anesthesiologists. More than 150,000 patients from six private anesthesiology practices were surveyed electronically about their experiences using a 19-question instrument. The survey incorporated elements recommended by the specialists' Committee on Performance and Outcome Measures. Automated contact via email followed, if necessary, by text message and phone calls with interactive voice response yielded a 25 percent response rate. On average, responses were received four days from receipt of contact information. Results and comments were continuously made available through portals accessible at the organization, division and practitioner levels. Patients were given the opportunity to provide additional feedback directly to the practice. Low scores (Likert 1 or 2) generated immediate alerts to both administrators and physicians.7
Within six months, the 1,127 anesthesia providers in six practices improved patient satisfaction scores by an average of 43 percent, or by two deciles, from the 47th to the 67th percentile. More impressive, practitioners from the lowest decile—those most at risk for liability suits—raised their patient satisfaction scores from the 3rd to the 40th percentile over the same six-month time frame. Most of that improvement occurred during the first 60 days—with no coaching, simply running the surveys and driving alerts to providers and administrators. 7 The study suggests that if the feedback is sent, anesthesiologists and anesthetists will, indeed, engage in selfhelp and improve.
The Move to Digital: Overcoming Pushback and Best PracticesResistance to change is not uncommon, and organizations that implement a digital patient experience of care solution may face some initial pushback. However, education of your hospital clients, internal administrators and practitioners is key to overcoming this resistance. All of these parties want to know why you are implementing a new solution. Sharing that real-time feedback leads to actionable improvement, increased awareness from practitioners and administration, and higher levels of communication should answer many of their questions. Carving out time to walk providers and administrators through navigating the solution and answering any questions they have will increase buy-in and go a long way in starting off on a positive note.
You may still encounter some pushback, typically from lower performers when compared to their peers. Realize that most practitioners have never had direct patient feedback, let alone had feedback sent to them in real-time or been compared to other high performers. Those who complain are a very small minority, well under one percent. Consistently, these individuals will find reasons they shouldn't be receiving feedback. Reasons like, "patients are complaining about survey saturation" or "it must be some other practitioner they were rating." It is important to demonstrate to the team that individual improvement is expected when these types of complaints are encountered. A physician lead once shared that a practitioner commented the email alerts were "annoying" and it would be the thing that pushed them "over the edge." In this instance, the physician lead handled the situation correctly by reiterating the purpose of the solution and suggesting the provider focus on improvement to lower the alert frequency.
By trial and error, some survey practices have been found to hurt the process more than others. Providing survey "count" incentives to management, keeping results from practitioners and allowing poor performers to lower morale and shut your patient experience down, all hinder improvement. One large group was paying administrator bonuses based solely on the number of paper surveys completed. As a result, paper surveys were run on clipboards in post-op and the results were never analyzed nor posted. Another group decided they didn't want the survey results shared with practitioners. Instead, a committee evaluated and leveraged the survey results for compensation, which led to no improvement and likely a sense of frustration from practitioners.
At the root of any successful organization is communication and education. Practices that have embraced digital solutions, adopted a continuous improvement mantra and driven timely feedback to both administrators and providers have found more success than their competitors—financially and with superior patient satisfaction scores.
Positive LeadershipTo truly effect change and reinvent, or to ensure you sustain as a top performing organization, you need to understand and apply fundamentals of effective leadership. A three-part leadership model looking at Self, Team and Atmosphere has found success among many organizations.
Self is about you as an individual, working toward excellence in all you do, having and being an effective mentor, and maintaining a healthy balance.
Team success requires proper communication, having the right people and being willing to hold team members accountable for their performance.
Atmosphere, oftentimes what people think about when they hear leadership, is something to implement after "self" and "team" are already in place. Creating the right environment, recognizing those deserving, maintaining enthusiasm and properly caring for the team round it out.
Our firm, SurveyVitals®, was founded upon, and has presented, a continuous improvement model for over a decade: Preparing, Performing and Perfecting.
- Prepare with positive expectations. If it is worth doing, it is worth doing well.
- Perform with the understanding you may be knocked down. Winners get back up and pursue relentlessly!
- Perfect your craft. Accept feedback, review your science and make needed adjustments. "Rinse and Repeat."
As additional reporting requirements continue to take shape, it is important to note that the CAHPS model may not be enough. Like it or not, digital solutions using 21st century communication tools (email and SMS) are the way of the future and administrators should look to adopt early. Truly monitoring the health of your organization and working toward improving your patient experience can have big monetary rewards—all too important in the face of shrinking budgets. Ultimately, committing to continual improvement and bettering patients' perceptions of care is simply doing the right thing by patients. However, reducing liability exposure, improving reimbursement, and increasing physician satisfaction and your bottom line are not too shabby side effects.
1Jones T. Shifting focus: turning patient satisfaction into patient loyalty. http://www.mgma.com/practice-resources/articles/fellow-papers/2010/shifting-focus-turning-patient-satisfaction-into-patient-loyalty-acmpe-fellow-paper-2010 Accessed April 18, 2016.
2Stelfox, HT, The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. (2005, October). American Journal of Medicine, 118(10). http://www.amjmed.com/article/%20S0002-9343%2805%2900164-6/abstract?cc=y?cc=y%20
3Matthew Collier, et al. Patient engagement: happy patients, happy margins https://www.accenture.com/%20t20151003T033201__w__/us-en/_acnmedia/Accenture/Conversion-Assets/DotCom/Documents/Global/PDF/%20Industries_17/Accenture-Happy-Patients-Healthy-Margins.pdf#zoom=50 Accessed June 15, 2016
4U.S. Centers for Medicaid and Medicare Services, CAHPS minimum business requirements https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_CAHPS_Minimum_Business_Requirements_3-4-2015.pdf Accessed May 5, 2016
5U.S. Centers for Medicaid and Medicare Services, The HCAHPS survey – most frequently asked questions. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/hospitalhcahpsfactsheet201007.pdf Accessed May 1, 2016
6Measuring the Anesthesia Patient Experience, Azam, Looke, Dalton et. al, American Society of Anesthesiologists: #A3030, 2014 http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=0BCE8D9C6BE288F964EC3B161DB88907?year=2014&index=15&absnum=3254
7Measuring the Anesthesia Patient Experience, Azam, Looke, Dalton et. al, American Society of Anesthesiologists: #A3030, 2014. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=%205CD1AF837A711268CAC73ACB70AB9E71?year=2014&index=15&absnum=3254