Research on Improving Patient Experience

Since the introduction of the CAHPS survey, researchers have studied the feasibility and value of using these surveys to support efforts to improve patient experience in various healthcare settings. This page summarizes recent and ongoing research by the CAHPS team related to:

• Improving patient experience with ambulatory care.
• Improving patient experience with hospital care.
• Improving patient experience in other settings.

Review all citations for quality improvement in the CAHPS bibliography.

Improving Patient Experience With Ambulatory Care

Reporting Patient Experience Information to Internal Users

As part of a larger collaborative research study with New York Presbyterian (NYP) that is investigating the feasibility, value, and use of the CAHPS Narrative Elicitation Protocol in ambulatory care practices, CAHPS researchers on the Yale team are testing a new feedback report. The design and delivery of this report reflects the preferences and suggestions of practice administrators, medical directors, clinicians, and staff. The team will be evaluating the value and use of this report for quality improvement through a pre-post comparison of results from an all-staff survey and in-depth interviews with the practice leaders, medical directors, clinicians and staff.

 Learn more:

• Implementing the New CAHPS Protocol for Obtaining Patient Comments About Their Care (Webcast). In this webcast about the pilot project with New York-Presbyterian, the speakers shared what they had learned about the characteristics of narrative feedback reporting strategies that are important to guiding improvement.

Assessing the Impact of Nurse Care Coordination

CAHPS researchers on the Yale team evaluated the impact of a nurse care coordinator program on patients' health and care experience, as well as staff interactions and work experiences, in 12 Connecticut community health centers. The research team used the CAHPS Clinician & Group Survey with the Patient-Centered Medical Home items and other supplemental items that ask about coordination of care to assess changes in patients' experiences of care.

Within 6 months of implementation, the team identified some positive effects of adding care coordination to nurses' roles, including a small improvement in patient experience for program enrollees and a significant increase in office visits for enrolled patients. The team also found that addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

 Learn more:

• Nembhard IM, Buta E, Lee YSH, et al. A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers. BMC Health Serv Res 20, 137 (2020). https://doi.org/10.1186/s12913-020-4986-0

In a complementary study of the role of creativity in quality improvement efforts, the research team concluded that the use of brainstorming and reflection tactics may help improvement leaders cultivate dynamics that increase the implementation of ideas that improve patient experience and healthcare delivery overall.

 Learn more:

• Lee YSH, Cleary PD, Nembhard IM. Effects of Leader Tactics on the Creativity, Implementation, and Evolution of Ideas to Improve Healthcare Delivery. J Gen Intern Med (2020). https://doi.org/10.1007/s11606-020-06139-9
• Research Snapshot from the Penn Leonard Davis Institute of Health Economics

Assessing the Use of Clinician & Group Survey Results in a Quality Monitoring and Improvement Program

Working with AltaMed Health Systems, a large Federally Qualified Health Center in California, CAHPS researchers on the RAND team are evaluating the use of shadow coaching under a pay-for-performance incentive tied to CAHPS Clinician & Group Survey measures. The goal of AltaMed's quality monitoring and improvement program is to improve physician-patient interactions and the performance of providers on their patient experience survey.

The research team found that shadow coaching improved providers’ overall performance and communication with patients immediately after being coached, Half of the recommendations provided by coaches to the coached providers encouraged consistency of existing behaviors and half encouraged new behaviors. However, the effects eroded over time as providers gradually slipped back into their previous habits of interacting with patients. As a result, the research team is assessing the influence of recoaching sessions using a wait-list control design and exploring whether the effects of shadow coaching are consistent across different patient groups.

 Learn more:

• Quigley DD, Qureshi N, Palimaru A, Pham C, Hays RD. Content and Actionability of Recommendations to Providers After Shadow Coaching. Quality Management in Health Care 2022. doi: 10.1097/QMH.0000000000000354. Epub ahead of print. PMID: 35170583.
• Quigley DD, Elliott MN, Slaughter ME, Burkhart Q, Chen A, Talamantes E, Hays RD. Shadow Coaching Improves Patient Experience with Care, But Gains Erode Later. Medical Care 2021. 59(11):950-960. doi: 10.1097/MLR.0000000000001629.PMCID: PMC8516705.
• Quigley DD, Qureshi N, Slaughter ME, Kim S, Talamantes E, Hays RD. Provider and Coach Perspectives on Implementing Shadow Coaching to Improve Provider-Patient Interactions. Journal of Evaluation of Clinical Practice 2021. 27: 1381-1389. doi.org/10.1111/jep.13575. PMID: 34014026.

Use of CAHPS Surveys in Patient-Centered Medical Homes (PCMH)

Implementation of PCMH and Decisions Related to Improving Patient Experience. CAHPS researchers on the RAND team conducted research with AltaMed, a large Federally Qualified Health Center in California, to identify the specific PCMH-related activities that may affect patient experiences, the successes and challenges involved in implementing these activities as they affect patient experience, and the usefulness of data from the CAHPS Clinician & Group Survey in this process.

 Learn more:

• Quigley DD, Mendel PJ, Predmore ZS, et al. Use of CAHPS^® patient experience survey data as part of a patient-centered medical home quality improvement initiative. J Healthcare Leadership 2015 Jul 7;(7):41-54. doi: http://dx.doi.org/10.2147/JHL.S69963.
• Quigley DD, Predmore ZS, Chen A, et al. Implementation and sequencing of practice transformation in urban practices with underserved patients. Qual Manag Health Care 2017 Jan/Mar;26(1):7-14. doi: 10.1097/QMH.0000000000000118.
• Quigley DD, Palimaru AI, Chen AY, et al. Implementation of Practice Transformation: Patient experience according to practice leaders. Quality Management in Health Care 2017 July/Sep;26 (3), 140-151. doi: 10.1097/QMH.0000000000000141.
• Setodji CM, Quigley DD, Elliott MN, et al. Patient experiences with care differ with chronic care management in a federally qualified community health center. Population Health Management 2017 Dec;20(6):442-448. doi: 10.1089/pop.2017.0003. Epub 2017 Apr 7.

Use of CAHPS PCMH Items during PCMH Transformation. CAHPS researchers on the RAND team studied 105 primary care practices sampled from across the US to learn how leaders and staff used CAHPS Clinician & Group Survey data during the process of becoming medical homes. Practice leaders participated in interviews and completed a practice-level PCMH assessment tool (PCMH-A) to monitor the medical home implementation process. The team found that practice leaders used CAHPS survey results to discuss best practices, share data with advisory councils, and improve provider performance.

 Learn more:

• Quigley DD, Qureshi N, AlMasarweh L, Pham C, Hays RD. Using CAHPS® Patient Experience Data for Patient-Centered Medical Home Transformation. The American Journal of Managed Care 2021. 27(9):e322-e329. e322-e329. doi:10.37765/ajmc.2021.88745. PMID: 34533915.
• Quigley DD, Slaughter ME, Qureshi N, Elliot MN, Hays RD. Practices and Changes Associated with Patient-Centered Medical Home Transformation. The American Journal of Managed Care 2021. 27(9):386-393. doi: 10.37765/ajmc.2021.88740. PMID: 34533908.
• Quigley DD, Qureshi N, AlMasarweh L, Hays RD. Practice Leaders Report Targeting Several Types of Changes in Care Experienced by Patients During Patient-Centered Medical Home Transformation. Journal of Patient Experience 2020. 7(6):1509-1518. doi: 10.1177/2374373520934231. PMCID: PMC7786645.
• Qureshi N, Quigley DD, Hays RD. Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home. Journal of General Internal Medicine 2020. 35(12):3501-3509. doi: 10.1007/s11606-020-06052-1. PMCID: PMC7728968.
• Quigley DD, Qureshi N. PCMH Transformation Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Data. Medical Home News 2021. 12(24): 1,5-6.
• Quigley DD, Predmore ZS, Hays RH. Tools to Gauge Progress during Patient-Centered Medical Home Transformation. The American Journal of Accountable Care 2017. 5(4):e8-e18.

Estimating the Magnitude of Differences in Patient Experiences Scores

CAHPS researchers on the RAND team conducted a systematic literature review of 22 articles that involved approaches to assessing the magnitude of differences in patient experiences scores between providers. Their research identified three main ways to develop estimates. The findings have implications for how differences in patient experience scores are interpreted when organizations assess the effectiveness of quality improvement efforts or trends in performance.

 Learn more:

• Quigley DD, Elliott MN, Setodji CM, et al. Quantifying Magnitude of Group-Level Differences in Patient Experiences with Health Care. Health Services Research 2018. 53(4): 3027-3051. doi: 10.1111/1475-6773.12828

Case Studies and Related Research on Improving Ambulatory Care

Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. This AHRQ guide informs developers of feedback reports about evidence-based strategies to consider when developing or refining a feedback reporting system.

A Tale of Three Practices: How Medical Groups Are Improving the Patient Experience (PDF, 508 KB). This evidence brief by Shaller Consulting for the Robert Wood Johnson Foundation's Aligning Forces for Quality program discusses the benefits of measuring and reporting patient experience data for quality improvement in clinical practice. The focus of the evidence brief is on demonstrable changes that have been achieved through specific improvement interventions in three medical practices.

Improving Customer Service at Health Share of Oregon (PDF, 279 KB). This case study discusses the strategies implemented by Health Share of Oregon, a coordinated care organization serving Medicaid recipients, to ensure that its customer service staff understand and meet the needs of its members. Health Share of Oregon was selected for this case study because of its high scores on the "Health Plan Customer Service" composite measure in the CAHPS Health Plan Survey as well as its improvement in one of the two survey items.  

How Two Provider Groups Are Using the CAHPS^® Clinician & Group Survey for Quality Improvement (PDF, 3 MB). This issue brief shares the experiences of two provider groups using the 12-Month version of the CAHPS Clinician & Group Survey to improve the delivery of care. It summarizes presentations delivered on an AHRQ-sponsored Webcast on October 8, 2013.

Improving Customer Service and Access in a Surgical Practice (PDF, 998 KB). This case study by the research team at RAND describes a surgical practice's successful implementation of a six-step plan to improve customer service and access for its patients.  

Improving Performance for Health Plan Customer Service (PDF, 1 MB). This case study by the research team at RAND focuses on the successful quality improvement methods employed by a health plan to improve customer service for its members. 

Providing Performance Feedback to Individual Physicians: Current Practice and Emerging Lessons. In a working paper, RAND researchers document what is known to date about reporting quality data back to physicians. This paper was based on a literature review as well as key informant interviews. 

Improving Patient Experience With Hospital Care

Assessing Efforts to Improve Pediatric Inpatient Care using Child HCAHPS

The RAND CAHPS team has partnered with UCLA Mattel Children’s Hospital to examine the use and value of data from the CAHPS Child Hospital (HCAHPS) Survey for improving pediatric inpatient care. The first phase of this study focused on evaluating the hospital’s implementation of initiatives to improve performance on two Child HCAHPS Survey measures: provider-family communication and responsiveness to the call button. The research team found that that hospital quality leaders and staff believe that the survey results accurately reflect their hospital’s quality of care, provide specific information for quality improvement, and can be used to improve pediatric care experiences.

The team also analyzed patients’ comments in response to one open-ended question on the Child HCAHPS Survey. They found that a large portion of the comments contained sufficiently specific information about what needs to happen to improve care.

 Learn more:

• Quigley DD, Slaughter ME, Gidengil C, Palimaru A, Lerner C, Hays RD. Usefulness of Child HCAHPS Survey Data for Improving Inpatient Pediatric Care Experiences. Hospital Pediatrics 2021. 11(10): e199-e209. doi: 10.1542/hpeds.2020-004283. PMID: 34548390.
• Quigley DD, Palimaru AI, Lerner C, Hays RD. A Review of Best Practices for Monitoring and Improving Inpatient Pediatric Patient Experiences. Hospital Pediatrics 2020. 10(3), 277-285. doi.org/10.1542/hpeds.2019-0243. Epub 2020 Feb 18. PMID: 32071119.
• Quigley DD, Predmore Z. What Parents Have to Say: Content and Actionability of Narrative Comments from the Child HCAHPS Survey. Hospital Pediatrics 2021. 12(2): 1-15. doi: 10.1542/hpeds.2021-006032.

The second phase of the study is evaluating how the use of a new open-ended Narrative Item Set in development for the Child HCAHPS Survey influences the hospital’s quality improvement process and reporting.

Survey of Hospital Quality Leaders

The RAND CAHPS team led an effort to learn more about the ways in which hospitals use the CAHPS Hospital Survey (HCAHPS) and other information about patient experience of care. The RAND team surveyed hospital quality leaders with primary responsibility for patient experience to collect information about:

• The role of HCAHPS in hospitals' efforts to improve patient experience.
• The types of quality improvement activities hospitals implement to improve their HCAHPS scores.
• Hospitals' perspectives on HCAHPS.
• The types of information collected by hospitals beyond those required for value-based purchasing.

The findings from this national survey will describe how hospitals use HCAHPS data and provide insight into the perceptions held by hospital leadership about patient experience measures including HCAHPS, and activities engaged in to improve patient experience. This information will allow hospitals to learn from their peers with outstanding records of patient experience.

Case Studies and Related Research on Improving Hospital Care

Improving Patient Experience in the Inpatient Setting: A Case Study of Three Hospitals (PDF, 561 KB). This case study by Shaller Consulting for the Robert Wood Johnson Foundation's Aligning Forces for Quality program discusses how three hospitals in different parts of the country achieved improvements in specific HCAHPS domains and shares five common themes in their approach to improving patient experience.

Improving Hospital Inpatient Nursing Care (PDF, 604 KB). This case study by the research team at RAND describes a large acute care hospital's successful implementation of a six-step plan to improve the emotional support provided to inpatients by the registered nurses and the rest of the nursing staff.

Improving Patient Experience in Other Settings

CAHPS In-Center Hemodialysis Quality Improvement Project. The CAHPS grantees and four ESRD Networks worked with a number of dialysis facilities to develop quality improvement initiatives based on CAHPS survey data.

 Learn more: Improving the Quality of In-Center Hemodialysis Care.