1. Measuring the Patients’ Experience with Care Disclosure Project Discussion Forum July 12, 2007 Dale Shaller, MPA Shaller Consulting Managing Director, National CAHPS Benchmarking Database d.shaller@comcast.net 651-430-0759

2. Presentation 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 CAHPS ® to measuring the patient experience? What is the unique contribution of CAHPS ® to measuring the patient experience? How is the nation’s health system performing on key CAHPS measures? How is the nation’s health system performing on key CAHPS measures?

3. IOM’s 6 Aims for Improvement Equity Efficiency Timeliness Patient-Centeredness EffectivenessSafety Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press: 2001.

4. IOM Definition “Health care that establishes a partnership among practitioners, patients, and their families…to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: 2001.

5. Picker Dimensions Respect for patient values, preferences Respect for patient values, preferences Coordination and integration Coordination and integration Information, communication, education Information, communication, education Physical comfort Physical comfort Emotional support Emotional support Involvement of family and friends Involvement of family and friends Transition and continuity Transition and continuity Access to care Access to care Gerteis M, et al. Through the Patient’s Eyes. San Francisco: Jossey-Bass: 1993.

6. Patient experience is strongly correlated with other key outcomes Health Outcomes: Health Outcomes:  Patient adherence  Process of care measures  Clinical outcomes Business Outcomes: Business Outcomes:  Patient loyalty  Malpractice risk reduction  Employee satisfaction  Financial performance Edgman-Levitan S., Shaller D. et al. The CAHPS Improvement Guide. Boston: Harvard Medical School: 2003.

7. Patients Who Experience Worse Hospital Care Are More Likely to Report Chest Pain 12 Months After AMI 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

8. Approaches to measuring patient experience with care Patient surveys Patient surveys  Proprietary tools  Public domain instruments (CAHPS) Focus groups and interviews Focus groups and interviews Walkthroughs Walkthroughs “Mystery shopping”: participant observation by trained informants “Mystery shopping”: participant observation by trained informants Web-based “convenience” reporting Web-based “convenience” reporting

9. Caveat emptor: example of consumer “convenience” reporting

10. The Evolution of CAHPS “CAHPS” = Consumer Assessment of Healthcare Providers and Systems “CAHPS” = Consumer Assessment of Healthcare Providers and Systems Most widely used survey tools for measuring the patient’s experience with care Most widely used survey tools for measuring the patient’s experience with care CAHPS Consortium initiated and funded by AHRQ since 1995: CAHPS Consortium initiated and funded by AHRQ since 1995:  CAHPS I: Focus on health plans and consumer choice  CAHPS II: Expansion of survey instruments  CAHPS III: New focus on QI and reporting applications Current consortium members include: AHRQ, CMS, AIR, RAND, Yale/Harvard, and Westat Current consortium members include: AHRQ, CMS, AIR, RAND, Yale/Harvard, and Westat

11. Expanding Suite of CAHPS Surveys Hospitals Hospitals Dialysis Facilities Dialysis Facilities Nursing Homes Nursing Homes Health Plans Health Plans Group Practices Group Practices Individual Clinicians Individual Clinicians Behavioral Health Organizations (ECHO) Behavioral Health Organizations (ECHO) Home Health Home Health Facility Care Ambulatory Care

12. Common CAHPS Design Principles Include reports and ratings of experiences – not “satisfaction” Include reports and ratings of experiences – not “satisfaction” Standardization to enable valid comparisons (through CAHPS Database) Standardization to enable valid comparisons (through CAHPS Database) Content based on evidence of what patients want to know and for which they are the best or only source of information Content based on evidence of what patients want to know and for which they are the best or only source of information Question items and survey protocols based on rigorous scientific development and testing, as well as stakeholder input Question items and survey protocols based on rigorous scientific development and testing, as well as stakeholder input

13. Common CAHPS Design Principles (continued) A core set of question items with option to add from a bank of tested supplemental questions: A core set of question items with option to add from a bank of tested supplemental questions:  Special populations (e.g., chronic conditions, persons with mobility impairments)  Quality improvement applications Focus on development of reports as well as survey instruments Focus on development of reports as well as survey instruments All CAHPS surveys and services are in the public domain All CAHPS surveys and services are in the public domain

14. CAHPS Health Plan Survey Over 138 million Americans are enrolled in health plans that are assessed using CAHPS Over 138 million Americans are enrolled in health plans that are assessed using CAHPS Major users: Major users:  Federal purchasers: CMS, OPM, DoD  NCQA: Health plan accreditation  State Medicaid Agencies  Health plans  Employer coalitions (e.g., NBCH eValue8)

15. Major Domains of CAHPS Health Plan Survey 4.0 Access: getting needed care Access: getting needed care Access: getting care quickly Access: getting care quickly Doctor communication Doctor communication Health plan customer service, information, and paperwork Health plan customer service, information, and paperwork Global ratings (overall care, health plan, personal doctor, specialist) Global ratings (overall care, health plan, personal doctor, specialist)

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

17. CAHPS Hospital Survey (H-CAHPS) Nation’s first standardized survey of inpatient experiences with care Nation’s first standardized survey of inpatient experiences with care Endorsed by National Quality Forum in 2005 Endorsed 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 increases  Public reporting in March 2008

18. Dimensions Measured by H-CAHPS Composites: Composites:  Communication with doctors  Communication with nurses  Communications about medications  Pain management  Cleanliness and quiet of hospital environment  Discharge information Overall rating Overall rating Willingness to recommend Willingness to recommend

19. 2006 H-CAHPS Composite Results National CAHPS Benchmarking Database. 2007 CAHPS Hospital Survey Chartbook. (May 2007)

20. CAHPS Clinician & Group Survey Adopted by AQA and submitted for endorsement by NQF Adopted by AQA and submitted for endorsement by NQF Adult, pediatric, and specialty versions Adult, pediatric, and specialty versions Core composites: Core composites:  Access: Getting appointments and care when needed  Doctor communication  Office staff courtesy and helpfulness Many supplemental items: Many supplemental items:  Health promotion and education  Shared decision making  QI items  Visit-specific questions

21. Implementation Models for CAHPS Clinician & Group Survey Regional collaboratives Regional collaboratives  BQI markets  Aligning Forces markets Accreditation/certification Accreditation/certification  American Board of Medical Specialties National health plan consortium National health plan consortium  CSS initiative Independent efforts Independent efforts  Health plans  Medical groups

22. Public Reporting of Survey Measures Out of 211 “report cards” in AHRQ’s Report Card Compendium: Out of 211 “report cards” in AHRQ’s Report Card Compendium:  113 include patient experience measures  69 health plan reports  20 medical group/clinic reports  19 hospital reports  3 nursing home reports  2 individual physician reports http://www.talkingquality.gov/compendium/in dex.html http://www.talkingquality.gov/compendium/in dex.html