• Adequacy of discharge information given by hospital staff or instructions for routine care for patients who use dialysis facilities.
“Patient experience items provide
more fine-grained information that is more useful to providers and facilities in making improvements to the care they give, information that is more actionable, understandable, specific, and objective than satisfaction ratings,” Dr. Crofton said. For example, “satisfaction” surveys
might gauge patients’ satisfaction with the time they had to wait in the physi- cian’s office. Patients who expect to be seen immediately might say a 10-min- ute wait was unsatisfactory; however, a 10-minute wait may satisfy patients not expecting to be seen within 20 minutes. Both groups “may have the same experi- ence but have very different levels of sat- isfaction. In contrast, CAHPS surveys ask how often patients were able to be seen within 15 minutes of their appointment time. Practices get actionable feedback that is unbiased by differing patient ex- pectations,” she said. She adds that the American Medical Association, as well as patients, facility staff, and other stakeholders provided input for the CAHPS survey’s develop- ment and testing. TMA leaders say how practices use
the results is perhaps more important than the survey itself. Dr. Fullerton says Baylor Scott &
White, with the help of an outside ven- dor, uses its survey results for quality im- provement programs to identify and ad- dress gaps in care, such as patient refusal to take medications. For example, one of his colleagues discovered his patient’s high cholesterol was not improving be- cause the patient got unsound advice from a hairdresser that such medications were harmful. “We view it as a quality initiative: It influences employee satisfaction, it influ- ences patient retention, and it influences patient trust,” he said. To keep costs down, North Hills
pulled together what Dr. Fuller describes as a standard patient satisfaction form. The practice surveys its patients every
52 TEXAS MEDICINE March 2014
six months, mostly on patients’ expe- riences with the care delivery process, such as wait times and physician and staff friendliness, and then shares that information with physicians and staff to target areas for improvement. Going forward, his practice envisions incorporating questions “geared more toward the medical encounter — How did the doctor communicate with you? Did you understand the treatment plan?
— because this [information] is going to have to do with outcomes,” he said. “If a patient’s blood pressure has not im- proved, but he doesn’t understand what he has to do, that affects the outcome.” Dr. Walters adds that it’s the behav-
iors the survey questions target that mat- ter. MD Anderson uses the feedback to help address physician behaviors that may influence patients’ perceptions of how well physicians care for them, such as how they communicate and listen or whether they sit with their back to the patient.
Proceeding with caution For some physician practices, the task is easier said than done. Houston internist and TMA Council
on Health Care Quality member Lisa Eh- rlich, MD, says her four-physician prac- tice plans to incorporate a patient feed- back tool in its patient portal. But she’s not optimistic that the potential PQRS penalty at stake will justify the expense. Nor is she convinced that patient satis- faction is necessarily tied to quality of care because patients’ perceptions can be what she describes as “highly” variable. “We don’t even know fully what mean-
ingful use [of electronic health records] has done for quality outcomes, and pa- tient satisfaction is even more subjec- tive,” she said. Harris County Medical Society
(HCMS) President Elizabeth Torres, MD, echoes those concerns and cautions against putting too much weight on pa- tient satisfaction scores. “These scores don’t reflect a good out-
come or a bad outcome for the patient. They don’t say the care was good or the care was bad. It’s a perception,” she said. “Now that may mean the doctor could communicate better or do things to im-
prove, and care might be better if that happens. But that alone is not an indica- tor of good care or bad care, a good out- come or a bad outcome. And we have to be careful about how this information is used and make sure it’s not the only basis for these [payment] decisions be- ing made.” She adds that HCMS conducted a
study of the Centers for Medicare & Medicaid Services (CMS) patient sat- isfaction mandates and survey vendor market and found that even though the CAHPS survey is free, physicians must follow a rigorous process to use it. For example, practices must use specific templates and disseminate the survey via phone or mail, which has an impact on staff time and practice costs. HCMS also found that as regulatory mandates kick in, more vendors are entering the patient satisfaction market, which even- tually could help lower survey costs, Dr. Torres says. Meanwhile, current CMS rules do lit-
tle to help smaller practices with those expenses. For 2014, CMS covers the cost of the CAHPS survey for group practices of 100 or more that are required to re- port patient satisfaction as part of PQRS. Groups of 25 to 99 physicians also must report PQRS quality data, but provid- ing patient feedback is optional. Those that choose to report it can report fewer PQRS quality measures, but CMS does not cover the cost. For more informa- tion on PQRS, visit TMA’s resource page,
www.texmed.org/pqrs. Dr. Fullerton recommends using a
third-party vendor to analyze the results if physicians want to reliably and scien- tifically compare themselves with their peers. But if that option is unaffordable, “every practice needs to have some way of measuring its service,” he says, even if the option is a paper questionnaire prac- tices distribute to patients and collect in a box.
While Dr. Walters believes the exer-
cise is worthwhile, he, too, acknowledg- es that it is not without flaws. Whereas the goal of patient surveys is to get their perspective on the entire care experience, the questionnaires themselves tend to be site-specific — for example, tailored per visit to a hospital or physician office —
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