By Christopher Guadagnino, Ph.D.
As physicians and hospitals experience growing pressure to increase the quality of their outcomes, enhance the safety of their patients and lower the cost of their care, analysts expect greater attention and scrutiny to be given to the accountability function of patient satisfaction scores, and to ways in which patient satisfaction measurement can be further integrated into an overall measure of clinical quality.
Variation in measurement tools, however, is an obstacle to making patient satisfaction a reliable part of the quality equation. Data on patient satisfaction is currently collected by various entities, for different purposes and at different levels in the health care system – including health plans, hospitals and physician practices. Only recently have efforts begun to bring uniformity to patient satisfaction measurement for hospitals, as part of a hospital report card initiative launched by the Department of Health and Human Services.
Even if redundancy and variation of patient satisfaction measurement can be minimized to permit meaningful comparisons across providers, questions remain as to how patient satisfaction surveys can be modified to fulfill an expanded role of quality of care measurement, whether it is even appropriate to consider patient satisfaction as a valid clinical quality indicator, what weight patient satisfaction should be given in the context of other quality of care measures, and what impact its expanded use will have on physicians’ practice and on malpractice liability.
Perhaps the largest context in which patient satisfaction is currently measured involves hospitals using patient surveys to assess and improve their “hotel-motel” functions and do a better service job to maintain a competitive posture in their markets, according to David Nash, M.D., associate dean and director, Thomas Jefferson University’s Office of Health Policy and Clinical Outcomes.
The hospital industry’s leading independent vendor of patient satisfaction measurement and improvement services – Press Ganey Associates, headquartered in South Bend, Indiana – specializes in producing tested and reliable surveys and national comparative databases. The firm’s clients include 40 percent of the nation’s acute care hospitals with over 100 beds and 30 percent of those with fewer than 100 beds, says Robert Wolosin, a Press Ganey research associate.
Press Ganey uses patient discharge information to select a sample of recipients who receive mailed satisfaction surveys, says Wolosin. Press Ganey’s core surveys were designed by focus groups of industry experts who developed lists of topics important to various aspects of health care, which were then tested and refined in test surveys, he explains. The company currently offers 35 surveys designed for various health care contexts, including general inpatient, pediatrics, emergency department, outpatient medical practice, ambulatory care, behavioral care, long term care and home health care. The majority of surveys use a five-point scale of responses ranging from “very poor” to “very good.”
Press Ganey can customize surveys to match the specific services offered by a hospital or clinic, and the firm has a consultant division that keeps abreast of any changes in the medical industry that might warrant survey alterations – as it did five years ago for its inpatient behavioral health survey, says Wolosin. The typical client, he notes, adds four or five customized questions to the 49 standard questions on Press Ganey’s inpatient survey.
Press Ganey’s survey data allows clients to compare their satisfaction scores to peer groups, e.g., hospitals with the same bed volume, to benchmark their scores, says Wolosin. Benchmarking may not be valid if comparisons are made to hospitals who use surveys of other vendors or different survey methods, he adds.
Patient satisfaction data regarding inpatient and ambulatory care play a significant role in the strategy and tactics a hospital uses in delivering patient services, says David Longnecker, M.D., senior vice president and corporate chief medical officer of the University of Pennsylvania Health System. In a competitive health care environment, patients want and expect better health care services than they did in the past, and medical centers are concerned about maintaining their overall image, he adds.
On a quarterly basis, Penn analyzes Press Ganey patient satisfaction survey results by hospital unit and also benchmarks for best practices across hospitals within the health system, using the data to make adjustments in areas such as efficiency of the admissions process, managing admission of patients to a clinical unit or bed, and maintaining sensitivity to the needs of patients, says Longnecker.
Penn also uses the data for quality monitoring and improvement efforts at its clinical practices. Each of Penn’s clinical practice sites receives regular reports of patient survey results, along with aggregate peer comparisons to all physicians in Penn’s specialty-specific departmental practices and its primary care practices, Longnecker notes. Department chairs work with the departmental practices to address service-related issues that are identified through the surveys, while a practice administrator works with the practice sites.
In response to patient satisfaction data, Penn changed the way its telephone system interfaces with patients and, over the past 18 months, has implemented a service excellence program in its clinical practices devoted to increasing the awareness of office staff to the needs and expectations of patients, focusing on issues such as improving telephone etiquette, reducing delays and scheduling appointments efficiently, says Longnecker.
UPMC Health System has used the results from Press Ganey patient satisfaction surveys to make changes such as adjusting patient appointment patterns for more realistic scheduling, says Marshall Webster, M.D., president of UPMC’s Physician Services Division and president of University of Pittsburgh Physician Practice Plan.
The very process of measuring patient satisfaction, says Webster, reinforces an ethos of quality by alerting patients that physicians are held accountable, and showing physicians that patients are pleased with the quality of care they receive. Webster notes that the physician ratings tend to be the highest scores of any category on the surveys, which he says continues to reinforce for physicians the positive relationships they foster with patients, who in turn encourage other patients to seek care at UPMC.
Health Plan Use
Health plans annually measure patient satisfaction as an external review and accreditation requirement by the National Committee for Quality Assurance (NCQA), which developed a member satisfaction survey as part of its HEDIS quality standards, as well as a recently updated version based on the federal Consumer Assessment of Health Plans Survey (CAHPS). CAHPS is currently used to assess the care provided by health plans covering over 123 million Americans, according to the Department of Health and Human Services.
From a business standpoint, health plans care about being able to show high CAHPS scores to prospective customers, and they compare their performance to previous years and to other plans, says Carey Vinson, M.D., medical director of quality improvement for Highmark Blue Cross Blue Shield.
Highmark looks at the CAHPS scores for its Keystone Health Plan West and Medicare HMO plans to identify areas of weakness and to make necessary changes with the input of its physician advisory committee. For example, on the issue of patients experiencing delays in receiving health care while awaiting health plan approval, Highmark has improved its scores over the years by making changes to its referral process, but has not been able to raise its scores to the level it desires. As a result, Highmark is going to remove the referral requirement on all of its commercial products by July 2004, and on its SecurityBlue plan by January 2005, says Vinson.
Although the CAHPS surveys include some items related to satisfaction with physicians, the survey is of minimal use for provider accountability, as it is not practice- or physician-specific and only breaks out data to the level of an insurer’s product, says Vinson.
UPMC Health Plan says other quality improvement feedback mechanisms are more useful than CAHPS in addressing provider-related concerns, such as the complaint and grievance process, and provider access and availability review.
Patient satisfaction scores play a more central role for primary care physicians – in the form of reimbursement bonuses for those with capitated payment contracts using a quality incentive payment system (QIPS). Using its own survey for capitated physicians, Highmark assigns patient satisfaction a weight of 15 percent toward the total QIPS score used to calculate bonus payments, with the balance governed largely by measures of clinical quality and other factors, says Vinson. Some other plans give patient satisfaction a higher weight in their bonus payment calculations, with some California plans giving it 100 percent weight – based on the philosophy that health care is a service industry business, Vinson notes. Highmark’s 15 percent weighting is intended to be enough so that physicians cannot ignore the service industry aspects of health care, says Vinson, who maintains that clinical care issues should remain paramount in importance.
Highmark feeds back patient satisfaction and clinical performance data to capitated physician practices, along with comparative data from the rest of Highmark’s network, in the hope that it will induce self-improvement efforts among physicians, says Vinson. Highmark has restricted the recredentialing of physician practices at a rate of five or six times per year because of low scores, usually resulting in a practice receiving a one-year renewal in Highmark’s network rather than a three-year renewal, Vinson explains.
Highmark has also used QIPS-related patient satisfaction data to create sample policies, handouts and flowsheets to help improve practice performance, covering issues such as how patients can reach a practice by telephone after normal business hours, says Vinson.
In its QIPS program, Independence Blue Cross (IBC) counts member satisfaction as 50 percent of primary care physicians’ practice quality assessment score, says I. Steven Udvarhelyi, M.D., IBC’s senior vice president and chief medical officer. IBC also uses survey data to monitor problems with quality of care, correlating the satisfaction data with transfer and complaint rates, and use of services, he notes. If concerns or problems are noted, he adds, IBC interviews practices that are outliers on these scores and asks them to implement improvements.
Patient satisfaction measurement also takes place at the level of physician office practice settings. The Medical Group Management Association (MGMA), which offers for purchase satisfaction questionnaires and procedural guidance on survey sampling and distribution techniques, says that patient satisfaction is eliciting more questions from medical practices than ever before and notes that competition is driving an interest among physician groups to satisfy their patients and address the requirements of purchasers and accrediting agencies.
Practices use the surveys to retain patient populations and attract more market share, to verify patient satisfaction results collected by managed care organizations, to help negotiate third-party contracts and to assess and measure specific initiatives, according to the MGMA.
Enthusiasm for patient satisfaction measurement may not be widespread across specialties, however. Rebecca Anwar, Ph.D., senior consultant with The Sage Group in Philadelphia, works primarily with surgical specialty groups and does not see much interest by physicians in patient satisfaction measurement, which she says could reflect a personality difference between physicians in surgical and medical specialties.
Practices that do wish to audit patient perceptions can acquire customized surveys to identify issues specific to the nuances of their practice, to identify services that they may need to add to the practice, to reinforce areas of excellent performance and to substantiate suspected problems. A radiology group, for example, discovered through surveys that patients found MRI scanners to be uncomfortably noisy and claustrophobic, and the practice developed ways to alleviate those effects, says Anwar. Surveys in other practices revealed problems such as a pattern of lateness to the office by a particular physician, inefficiency and rudeness of staff and accessibility problems in the front office, Anwar adds.
Patient satisfaction data are also valuable for staff training, morale-building and creative marketing, says Anwar. Physicians in one practice wore a pin that referenced a patient satisfaction score by saying: “95 percent, going for 100.” The pin elicited questions by curious patients that gave physicians and staff the opportunity to answer enthusiastically. Other practices have designed patient education materials on the basis of questions patients repeatedly asked in written survey responses, she adds.
Future Expansion and Constraints
Given the push toward increased provider accountability and health care quality improvement initiatives, there is no question that the attention and weight given to patient satisfaction is going to increase, says Nash.
Press Ganey argues that satisfaction data represents real events that transpire between providers and patients, and that it needs to be seen as equivalent to clinical indicators as a parameter of quality of care. The patient is the final arbiter of what the experience of care has been, says Wolosin: “If you do not pay attention to it at some level, you will not understand how your processes can be improved so that the patient can walk away with an experience that is multidimensionally okay.”
Udvarhelyi says that satisfaction is related to the overall effectiveness of communication between physician and patient, which he says is necessary for achieving good outcomes, while ineffective communication can lead to poor quality. “Satisfying the patient and addressing their concerns is an outcome in and of itself,” says Udvarhelyi. “The patient is the best judge of whether their needs are being met.”
The changing ethos of medicine has led to an increased sensitivity to patient satisfaction, Wolosin maintains: “Patients as persons, and not just as bodies that bear pathology, is an idea whose time is here. There is no doubt that ‘patient as person’ is the dominant model in most American medical institutions.”
A recent Institute of Medicine report outlined six characteristics of quality health care: that it is safe, equitable, evidence-based, timely, efficient and patient-centered, notes Longnecker. The latter three goals, he says, are directly influenced by patient satisfaction. Hospital surveys have made physicians much more aware of patients’ expectations of service quality as a separate component of quality of care, says Longnecker, who believes those expectations have gone up considerably over the past few years.
An increased focus on enhancing relationships with patients can result in a reduction in medical errors, argues Wolosin, to the extent that it makes patients more comfortable asking physicians questions about their medications and treatment. As the patient population ages and presents providers with more chronic aliments, better provider-patient relationships will lead to better self-care by patients, he says.
Press Ganey also believes that more satisfied patients are less likely to file medical malpractice lawsuits. Wolosin points to a June 2002 study in the Journal of the American Medical Association that found that lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for physicians’ volume of clinical activity.
Lack of comparability of patient satisfaction data, however, remains an obstacle to its expanded use. Measured by different entities, for different purposes, using different instruments, patient satisfaction data is far from uniform.
Perhaps the most significant effort to increase its uniformity and to make patient satisfaction a more integral part of health care quality is the Centers for Medicare & Medicaid Services’ (CMS) hospital report card initiative. CMS is piloting a newly-developed HCAHPS survey in three states – New York, Maryland and Arizona – in the hope of collecting data that permits valid comparisons among hospitals to help consumers select a hospital and to create incentives for hospitals to improve the care they provide. CMS expects to have a national implementation strategy for HCAHPS by early 2004, after which it will publish collected data on its website. CMS says participation in the initiative will be voluntary and that it has no plans to use HCAHPS scores for hospital reimbursement.
CMS also has plans to adapt the CAHPS survey for use in assessing individual physician practices.
Even if the data is made uniform, hospital surveys provide a minimal degree of feedback to physicians about service performance, except in the rare case that a patient specifically mentions a physician by name in the comments section of the survey, says Nash. Efforts have recently begun to increase such feedback, as some hospitals have approached Press Ganey to design survey instruments to target improvement efforts with particular units in the hospital, such as cardiovascular and pulmonary disease, says Wolosin.
The biggest single methodological obstacle to expanding the use of surveys to targeted groups of patients is the ability to collect a large enough sample from each group to yield valid results, says Roseann Carothers, account executive for The Myers Group, a private contractor that conducts CAHPS surveys for health plans. Data must also be collected monthly or quarterly to avoid making generalizations based on annual snapshots, she adds. The NCQA is already beginning to see declining response rates for its CAHPS surveys, which Carothers says may be a result of patients being oversurveyed by numerous sources.
Survey expansion also raises the question whether patient satisfaction measurement should broaden its focus beyond quality of service and begin to measure perceptions of clinical outcomes. Some believe that patient surveys should add more specific questions about clinical quality to open a new window on provider care practices and further drive quality improvement, while others see fundamental barriers to integrating perceptions of service and clinical quality.
While satisfaction measurement is still being used primarily to monitor and improve service excellence, some hospitals are beginning to ask more sophisticated, clinically-oriented patient satisfaction questions, such as whether a person felt safe during hospitalizations and whether they observed a medical error occur, says Nash. “As the science of the measurement improves, I’m sure we’ll be asking patients their concerns in these areas,” he adds.
As patients become more sophisticated in their understanding of provider report cards, outcomes and complications rates, their perceptions of clinical quality should increasingly become part of their evaluation and satisfaction ratings, says Longnecker.
Highmark plans to include more clinically-specific questions in the next round of its member satisfaction surveys. While most clinical quality indicator information can be extracted from claims data, there are certain aspects of care for which there is no claim, such as how much effort is made by physicians to talk about smoking cessation, says Vinson. After it collects baseline data on the new clinically-specific questions, Highmark may incorporate physician scores on the new items into their QIPS bonus calculation, Vinson adds.
Vinson believes there is going to be some movement in the industry toward asking patients more direct questions about the perceived level of the quality of care delivered, such as whether they were given the wrong medicine, whether the provider made the diagnosis accurately, and whether the patient got better. But such a trend has limitations, which Vinson acknowledges. Patient perception data about clinical processes and outcomes may lack validity, and not many tools currently exist to measure what is going on inside a hospital or a physician’s office, he notes.
UPMC’s Webster also believes that patient satisfaction measurement is best kept to the quality of service side rather than become integrated with quality of care issues. “I don’t think that the Press Ganey survey is the kind of instrument that is helpful in us looking at very objective measurements of quality of care,” says Webster. “We want specific, objective, measurable things that attest to the quality of care that we are providing – for example, one-year survival after liver transplants,” he notes.
Preliminary research on the relationship between perceptions of care quality and actual outcomes highlights the difficulty of integrating the two in a patient survey. An October 2003 Center For Studying Health System Change report noted a study in which emergency department patients who waited more than an hour for treatment rated the thoroughness of their exam as very good or excellent far less frequently than did patients who waited 15 minutes or less. While longer waiting times increase patient frustration, it was unknown whether large differences in waiting time reflected actual differences in clinical quality. Patient perceptions of emergency department care quality were also much lower than perceptions of care quality at other ambulatory care providers, even for patients with similar waiting times.
Webster illustrates both the importance and limitations of expanded patient satisfaction measurement in his comment: “The perfect health care delivery is a perfect outcome and a perfectly happy patient.”