Section 6: Strategies for Improving Patient Experience with Ambulatory Care
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6.A. Overview of Strategies
The steps you take to assess patient experience with care in your organization and explore what is driving those experiences will enable the quality improvement team to identify opportunities to improve and establish goals. As discussed in Section 4 of this Guide, the next step in the quality improvement process is to identify possible strategies. Your team may have several ideas for improvement strategies based on its evaluations of care delivery processes and input from stakeholders. To supplement and help to organize those ideas, this section presents selected strategies for improving the experiences of patients and enrollees as measured by the CAHPS surveys.
The strategies are intended to address the various topics covered by CAHPS surveys of ambulatory care, with an emphasis on the three core survey domains of access to health care, communication, coordination of care, and customer service. Table 6-1 lists sixteen strategies you could consider and the survey topics they address. Appendix 6a provides a crosswalk of these topics and the measures derived from different CAHPS surveys (all of which are variations on the CAHPS Health Plan Survey or the CAHPS Clinician & Group Survey).
These strategies represent a range of possible solutions. Some are easy and inexpensive to implement, while others are more logistically complex and require a significant investment of money, time, and other resources. If your team wants to pursue a more intensive strategy, it can help to "start small" by breaking down the strategy into smaller components and tackling one component at a time. Also, some strategies may allow you to see results right away, while others may require time to make a measurable difference; your team will need to work with the organization's leaders to decide which approach would be best.
Finally, it is important to note that these strategies are directed at different audiences. Some strategies are aimed at physician practices and medical groups because they address aspects of care that happen in the doctor's office, such as access to care (e.g., scheduling appointments and receiving timely care and information), communication between providers and patients, interactions with office staff, shared decision making, and self-management support. Other strategies address experiences within the domain of health plans, such as member services, information to manage health care and costs, and health promotion and education. For some strategies, both health plans and provider groups have a role to play, even if one is more "responsible" than the other for an aspect of patient experience. Health plans, for example, can equip providers with the skills, tools, and information systems they can use to improve their communication with patients. Health plans can also play a very important role in motivating medical groups, practices, and individual physicians to improve patient experience. Appendix 6b discusses three ways in which health plans can harness reporting and purchasing strategies to focus attention on the experience of care.
|Strategy||Access to Care & Information||Communication with Patients||Coordination of Care||Customer Service||Health Promotion/Education|
|Open Access Scheduling for Routine and Urgent Appointment (6.A)||X|
|Internet Access for Health Information and Advice (6.D)||X||X|
|Rapid Referral Programs (6.E)||X||X|
|On-Demand Advice, Diagnosis, and Treatment for Minor Health Conditions (6.F)||X||X|
|Training To Advance Physicians' Communications Skills (6.G)||X||X||X|
|Tools To Help Patients Communicate Their Needs (6.H)||X||X|
|Shared Decision-Making (6.I)||X||X|
|Support Groups and Self-Care (6.J)||X|
|Cultivating Cultural Competence (6.K)||X|
|Planned Visits (6.L)||X||X||X|
|Group Visits (6.M)||X||X||X|
|Price Transparency (6.N)||X|
|Service Recovery Programs (6.P)||X|
|Standards for Customer Service (6.Q)||X|
|Reminder Systems for Immunization and Preventive Services (6.R)||X||X||X|
The tables below list composite measures derived from the standard items in each survey, i.e., the items included by every user of that specific survey. Many other topics, including some of the domains in the left column, are covered by supplemental items that users can choose to add to their surveys. The tables do not include the global rating measures.
|Domains for Patient Experience||Clinician & Group Survey 3.0||CAHPS Surveys for Accountable Care Organizations (ACOs)*,**||CAHPS for Physician Quality Reporting System (PQRS) Survey**|
|Access to care||Getting Timely Appointments, Care, and Information||Getting Timely Appointments, Care, and Information (9 & 12)
Between Visit Communication (12)
|Getting Timely Appointments, Care, and Information
Between Visit Communication
|Communication||How Well Providers Communicate with Patients||How Well Providers Communicate (9 & 12)||How Well Providers Communicate|
|Office Staff||Helpful, Courteous, and Respectful Office Staff||Courteous and Helpful Office Staff (9 & 12)||Courteous and Helpful Office Staff|
|Coordination of care||Providers' Use of Information to Coordinate Patient Care||Care Coordination (12)||Care Coordination|
|Self-management||Talking with You About Taking Care of Your Own Health (from the Patient-Centered Medical Home Item Set)||Helping You Take Medications as Directed (12)||Helping You Take Medications as Directed|
|Shared decision making||(not included)||Shared Decision Making (9 & 12)||Shared Decision Making|
|Health promotion and education||(not included)||Health Promotion and Education (9 & 12)||Health Promotion and Education|
|Access to specialists||(not included)||Access to Specialists (9 & 12)||Access to Specialists|
|Cost of care||(not included)||Stewardship of Patient Resources (9 & 12)||Stewardship of Patient Resources|
*In 2016, CMS accepted results for two versions of the ACO Survey: ACO-9 and ACO-12.
**Health Status/Functional Status is not included as a composite measure for the purposes of this table because the questions are not asking about the patient's experience with care.
|Domains for Enrollee Experience||Health Plan Survey 5.0||Medicare Advantage CAHPS Survey||Qualified Health Plans (QHP) Enrollee Survey|
|Access to care||Getting Needed Care
Getting Care Quickly
|Getting Needed Care
Getting Appointments and Care Quickly
|Getting Needed Care
Getting Care Quickly
|Communication||How Well Doctors Communicate||Doctors Who Communicate Well||How Well Doctors Communicate|
|Customer service||Health Plan Customer Service||Health Plan Information and Customer Service||Health Plan Customer Service|
|Coordination of care||(not included)||Care Coordination||How Well Doctors Coordinate Care and Keep Patients Informed|
|Cultural Competence||(not included)||(not included)||Getting Information in a Needed Language or Format|
|Access to Information||(not included)||(not included)||Getting Information about the Health Plan and Cost of Care|
|Costs||(not included)||(not included)||Enrollee Experience with Costs|
Many of the measures in the CAHPS ambulatory surveys address issues outside of the direct control of health plans, because the locus of the care or service lies at the medical group or practice level. However, health plans can exert some influence on medical groups and individual physicians, encouraging and motivating them to improve the patient's experience in the doctor's office. The degree of influence a plan can exert depends in part on the structure of its relationship with its provider network. Health plans that own physician practices and/or employ physicians, and those that have an exclusive relationship with their contracted providers, tend to have more influence than those that account for only a small share of a medical group's patients.
This section outlines a few ways in which health plans can encourage medical groups and physician practices to take steps to improve patient experience:
- Public Reporting on Provider Performance
- Private Feedback on Provider Performance
- Value-Based Payments
6b.1. Public Reporting on Provider Performance
Public reporting on provider performance can help patients make more informed choices about which health systems, hospitals, medical groups, and individual physicians best meet their needs. In addition, making such information publicly available encourages providers to engage in quality improvement activities in areas where their performance lags.1-5
Public Reporting Can Stimulate Improvement
Since initiating public reporting of patient survey scores and patient comments about physicians, the University of Utah Health Care has seen a significant increase in physician communication scores, from the 35th percentile in 2010 to the 90th percentile in 2014. Public reporting has also led to a doubling of website traffic.*
*Source: Embracing Transparency: Valuing Patients As Informed Consumers. Feb 2013.
Working independently and in collaboration with other stakeholders (e.g., large employers, local purchasing coalitions, government purchasers), health plans have been active in developing public "report cards" on provider performance—primarily on the web but sometimes in print. These reports provide comparative information on the performance of hospitals and medical groups on various measures of quality, including but not limited to CAHPS survey measures. By making these reports available, health plans encourage their members to pay attention to the quality of their providers and to select high-performing medical practices and physicians.6 As part of these programs, health plans can also publicly recognize high-performing providers in their network.
The following examples describe health plan efforts to work with other stakeholders to develop and publicly report on patient experience with providers:
- The Wisconsin Collaborative for Healthcare Quality (WCHQ), a multi-stakeholder, voluntary consortium of Wisconsin health plans, health systems, medical groups, and hospitals, has been publicly reporting provider performance on quality measures since 2004. WCHQ's online Performance & Progress Report on clinics and medical groups shows scores for six composite measures from the CAHPS Clinician & Group Survey: "Getting Timely Appointments, Care, and Information," "How Well Providers Communicate," "Helpful, Courteous, and Respectful Office Staff," "Follow Up on Test Results," "Overall Provider Rating," and "Willingness to Recommend." For large medical groups, the results are broken down by specialty.7
- Massachusetts Health Quality Partners (MHQP) is a coalition of health plans, physicians, hospitals, purchasers, patient and public representatives, academics, and government agencies that has worked to improve the quality of health care services in Massachusetts. Among other activities, MHQP collects and publicly reports on the performance of over 500 physician practices on various quality metrics, including patient experience measures from MHQP's statewide Patient Experience Survey, which is based on the CAHPS Clinician & Group Survey.
6b.2. Private Feedback on Provider Performance
As a substitute or complement to public performance reports, health plans can also feed useful information to health care providers—including administrative leaders and staff—through private reports that evaluate their performance on various aspects of quality, including patient experience. In some cases, health plans share private reports first, and then introduce public reports after providers become more comfortable with the assessment of quality and the methodology being used. Private reports often contain more detailed information than that available in public reports, thus helping providers to pinpoint more precisely those aspects of the patient experience that are in need of improvement. For example, private reports may include results for individual survey items as well as summaries of patients' complaints and feedback, thus providing insights into common problems that need to be addressed.8
Private reports also typically offer more detailed comparisons of individual provider and/or group performance to that of peers and other benchmarks, such as local, regional or national norms and "best-in-class" performance. This comparative data not only encourages a sense of competition among providers to improve, but also may stimulate conversations among doctors and other clinicians about ways to improve performance on patient experience and other quality measures.
Examples of health plan initiatives to compile and disseminate private reports to network providers that include CAHPS or other patient experience survey measures include the following:
- In 2005, HealthPlus of Michigan (an independent health plan) began privately reporting detailed performance data from the CAHPS Clinician & Group Survey to PCPs that direct primary care for enrollees in the plan's commercial HMO product. In combination with information on best practices, this feedback helped to stimulate steady improvement in both CG-CAHPS and CAHPS Health Plan Survey scores over a 7-year period through 2012.9
- In addition to public reporting, Massachusetts Health Quality Partners distributes private reports to all medical practices that participate in the statewide Patient Experience Survey.
- In the public sector, the Centers for Medicare & Medicaid Services (CMS) provides each group practice participating in the CAHPS for PQRS Survey with survey results in an individualized, detailed report. These reports describe the content of the survey and include the group practice's scores on both the summary measures and individual questions in the survey, comparison scores and, where applicable, trend data showing how a practice's results from the previous reporting period compare to results from the current one. CMS provides a similar feedback report to convey results from the CAHPS Survey for ACOs to those organizations participating in the Medicare Shared Savings and Pioneer Programs.
6b.3. Value-Based Payment
Health plan payments to providers can be a critical lever for creating incentives to providers to improve the patient experience. Many health plans have already implemented pay-for-performance (P4P) and other payment programs that financially reward the provision of "high-value" care—i.e., care that is high quality, cost-effective, and person-centered. Such value-based payment programs typically tie payment to performance on a wide array of quality and cost measures, including those that evaluate clinical processes, patient safety, utilization of health care resources, structural elements of care, clinical outcomes (e.g., readmissions, mortality, complications), and costs (e.g., total cost of care, cost per episode). By incorporating Clinician & Group Survey measures into these payment systems, health plans can create meaningful incentives for providers to improve the patient experience.10,11
For P4P and other value-based payment programs to be successful in stimulating improvement, health plans and providers must come to a mutual agreement on the size and structure of the incentives, and not hesitate to tie a meaningful portion of payments to performance on a manageable number of measures.12-14
Examples of value-based payment programs that incorporate patient experience measures include the following:
- Blue Cross Blue Shield of Massachusetts (BCBSMA) developed the Alternative Quality Contract (AQC) payment system, which pays providers a population-based, global budget combined with significant financial incentives tied to performance on a broad set of quality measures, including CAHPS measures. By its fourth year of operation, the AQC had led to cost savings of nearly 10% while simultaneously improving quality performance, including patient experience scores. BCBSMA is now using AQC with its new health insurance products so as to create significant incentives for members to choose high-value providers and make high-value care choices, which in turn has encouraged them to participate actively in discussions with health care providers about quality and value.15
- The Integrated Healthcare Association (IHA), a multi-stakeholder group in California that includes health plans, administers a statewide P4P program in which participating commercial HMOs use common measures to evaluate the performance of contracted physician groups and pay bonuses tied to that performance. Measures evaluate both clinical processes and patient experience.
3. Elliot MN, Cohea CW, Lehrman WG, et al. Accelerating improvement and narrowing gaps: trends in patients' experiences with hospital care reflected in HCAHPS public reporting. Health Serv Res 2015 Apr. [Epub ahead of print]
4. Alexander JA, Maeng D, Casalino LP, et al. Use of care management practices in small- and medium-sized physician groups: do public reporting of physician quality and financial incentives matter? Health Serv Res 2013 48:376-97.
7. The Wisconsin Collaborative for Healthcare Quality Performance and Progress Report is accessible at http://www.wchq.org/reporting/.
8. Gerteis M, Harrison T, James CV, et al. Getting behind the numbers: understanding patients’ assessments of managed care. New York: The Commonwealth Fund; November 2000. Publication 428. Available at: http://www.commonwealthfund.org/publications/fund-reports/2000/dec/getting-behind-the-numbers--understanding-patients-assessments-of-managed-care.
11. Damberg CL, Sorbero ME, et al. ASPE Research Report: Measuring Success in Health Care Value-Based Purchasing Programs. Summary and Recommendations. Available at http://aspe.hhs.gov/health/reports/2014/HealthCarePurchasing/rpt_vbp_summary.pdf.
12. Arcadia. Pay-for-Performance (P4P) Strategies for Health Plans and Provider Networks: Building Collaboration through Technology, Shared Value, and Trust. 2013. Accessible at http://content.arcadiasolutions.com/hs-fs/hub/358257/file-793806811-pdf/White_Paper_p4p.pdf.
15. More information can be found at Massachusetts Payment Reform Model: Results and Lessons and National Quality Strategy Webinar: Using Payment to Improve Health and Health Care Quality.