1. Perceptions of Specific Clinician Behaviors Linked to Health Care Quality Karen Shore, PhD Roger Levine, PhD Julia Mitchell, MS Margarita Hurtado, PhD Kristin Carman, PhD Steven Garfinkel, PhD Jim Lubalin, PhD AcademyHealth Annual Research Meeting Boston, MA June 28, 2005 Funding: Agency for Healthcare Research and Quality (AHRQ)

2. Overview of Critical Incident Technique  Systematic, qualitative research method  Used to collect and analyze reports of behaviors associated with specific outcomes  Highly focused on providing solutions to practical problems

3. Criteria for A “Good Incident"  The incident describes a SINGLE behavior  The behavior is CRITICAL to the outcome  Another person can understand what is going on  Non-essential information is eliminated  Unstated inferences do not have to be made

4. Study Goals  Develop a comprehensive taxonomy of the components of quality ambulatory health care, based on both patient and clinician perspectives  Use this taxonomy to identify factors associated with quality care that are not being assessed in existing CAHPS draft survey instrument  Develop draft items for inclusion in CAHPS survey

5. Study Design  In-depth interviews (45-60 minutes)  Providers (physicians, nurse practitioners, and physician assistants)  Patients (4 different race/ethnicity groups)  Goal of interviews – elicit examples of specific behaviors that are responsible for good quality health care or poor quality health care  Categorize provider and staff behaviors responsible for the quality of care into a taxonomy of behaviors

6. Population Studied About 20 providers and 80 patients from each of two geographic locations (Chicago and Hawaii) A total of 3,011 specific behaviors were collected from 207 respondents 13.7 specific behaviors/patient respondent, on average 17.7 specific behaviors/provider respondent, on average

7. Example of Patient Critical Incident What was the situation? I went to see an internist for a regular physical. What happened? What did the person do? He checked my heart, my glands, my back, my temperature, my reflexes, etc. It was fast. He explained what he was doing as he was doing it, as well as what he was looking for and what he was not. My blood pressure was a little high. I told him I do eat a lot of salt. He told me to cut down on the sodium.

8. Example of Provider Critical Incident What was the situation? A patient with chronic knee pain came in. He was recently diagnosed as also being diabetic. His most recent lab tests were abnormal. What happened? What did you do? I reviewed his chart about his present complaint and his family history. I asked him if he knew about diabetes or if he knew anyone who had it. He knew just the basics. I went over the lab data with him. I asked him to go through diabetes education with a nurse-trainer. When he agreed, I made an in-house referral to diabetes education that is part of our medical group.

9. Major Taxonomic Categories  Clinical skills (34% of all incidents)  Rapport (28%)  Health-related communication (21%)  Office practices (8%)  Patient advocacy (5%)  Accessibility/ availability (3%)  Information seeking (2%)  Above & beyond (1%)  Ethical behavior (<1%)

10. Examples of Subcategories within Health-related communication  Provides literature, diagrams, models, or refers to websites  Explains medical condition thoroughly and in terms patient/caregiver can understand  Provides information on non-medical ways patient can care for self (lifestyle changes) or for condition (includes classes, counseling)  Gives patient complete and accurate information and/or instructions regarding tests, treatment, treatment options, treatment plan, medications, follow- up care, post-operative care

11. Findings – Patient Characteristics (More Likely to Mention) Provider Behavior Related to… HispanicFemale Age >50 Health-related communication + Accessibility/availability ++ Clinical skills +++ Prescribing or recommending appropriate/effective medication or other treatment + Giving appropriate referrals ++ Ensuring patients get needed care ++ Facilitating access to medications or medical supplies ++ Above and beyond +++ Note: +++ = significant at p<.01, ++ = significant at p<.05, + = significant at p<.10

12. Findings – Patient Characteristics (Less Likely to Mention) Provider Behavior Related to… Hispanic Asian or Pacific Islander African American Age >50 Courtesy and respect + Giving patient complete and accurate information regarding treatment + Ordering tests +++ Giving appropriate referrals +++ Ensuring patients get needed care + Note: +++ = significant at p<.01, ++ = significant at p<.05, + = significant at p<.10

13. Findings – Patients vs. Providers (More Likely to Mention) Provider Behavior Related to…PatientsProviders Rapport +++ Engaging patient (e.g., asking about patient or family) +++ Asking questions (rapport or clinical) +++ Providing information on non-medical ways patient can care for self or condition ++ Ensuring patients get needed care +++ Information seeking (e.g., reviewing patient’s medical records) +++ Note: +++ = significant at p<.01, ++ = significant at p<.05

14. Conclusions  Individuals with different demographic characteristics appear to value different aspects of health care quality, as do patients and providers.  To ensure patient satisfaction with the quality of care they receive, providers may need to modify their behaviors or emphasize different aspects of the encounter based on the demographic characteristics of the patient.

15. Policy Implications  This study presents important information regarding ….what patients and providers value in a health care encounter, and ….the extent to which the concept of health care quality differs by patients’ demographic characteristics.  This information can be used ….in quality improvement efforts, and ….in developing policies and practices that effectively address the areas of greatest concern to patients.

16. Contact Information Karen K. Shore, PhD American Institutes for Research kshore@air.org 650-843-8121 (phone)