Confirming and Supplementing CAHPS® Communication Items Using Feedback from High-Performing Physicians

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Slide 1

Confirming and Supplementing CAHPS® Communication Items Using Feedback from High-Performing Physicians

Ron D. Hays, Ph.D.,
Professor of Medicine and Health Services, UCLA.
Denise D. Quigley, Ph.D.,
CAHPS Quality Improvement Team, RAND.
AHRQ Conference.

September 11, 2012 (8-9:30am session)

Image: The RAND HEALTH logo is shown.

Slide 2

Presentation Outline

• Why focus on doctor-patient communication?
• Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective?
• Feedback from high-performing physicians.
• Summary and implications.

Slide 3

Presentation Outline

• Why focus on doctor-patient communication?
• Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective?
• Feedback from high-performing physicians.
• Summary and implications.

Slide 4

Doctor-Patient Communication Is Critically Important to Patients

• Good communication skills are among the qualities most desired:
  • Doctor listens to patient concerns.
  • Doctor explains health problems clearly.
• Effective communication is key to positive patient-doctor relationships.
• Patient reports about communication are strongly associated with global ratings.

Slide 5

Communication Measures used to Improve Patient Experience

• Quality improvement.
• Element of pay-for-performance systems.
• Recognition as a patient-centered medical home.

Slide 6

Presentation Outline

• Why focus on doctor-patient communication?
• Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective?
• Feedback from high-performing physicians.
• Summary and implications.

Slide 7

CAHPS Surveys Address Communication from Patient Perspective

• During CAHPS development, consumers identify important aspects of care.
• Patients are the best or only source of information for most measures.
• Clinician and Group (CG) CAHPS topics include:
  • Doctor-patient communication.
  • Access.
  • Coordination of care.
  • Courtesy and helpfulness of office staff.
  • Overall rating of doctor.

Slide 8

Physicians Have Invaluable.Perspective on Communication Items

• As CAHPS stakeholders, physicians are consulted during CAHPS survey development.
• But physicians are not interviewed about best practices related to communication.

Slide 9

We Asked High-Performing Physicians...

How well do the CAHPS survey items capture the important elements of doctor-patient communication?

Slide 10

Existing Collaboration with Health Plan Facilitated Exploratory Study

Health plan:

• Has 72,000 adult, commercial HMO members.
• Administers CAHPS clinician-group survey annually (2005-2012).
• Uses CAHPS for P4P, Q.I., and reporting.
• Was interested in physician perspective.
• Gave us physician-level CAHPS data and contact information.
• Permitted us to contact their physicians.

Slide 11

High-Performing Physicians on .CAHPS were Identified

• 2008 CAHPS data:
  • 20,141 patients among 259 primary care physicians (46% response rate).
• Calculated overall z-score (0-100 score):
  • Average of CAHPS composites (access, communication, office staff) and global rating of physician.
• Rank ordered the 259 doctors by z-score.

Slide 12

Physician Interviews.

• Contacted the 40 highest-ranked doctors; interviewed 11 physicians who were willing.
• Used a semi-structured, open-ended protocol with 36 questions:
  • Basic information about practice.
  • Philosophy of providing good care.
  • Communication behaviors during patient visits.
  • Office practices related to communication.
• Taped and transcribed interviews.

Slide 13

Themes Coded...

• Coded the content of the interviews for important themes.
• Created unique counts of codes per physicians; found 16 themes.
• Two researchers independently coded the presence or absence of each of the 16 themes:
  • Calculated a pooled kappa to assess.inter-rater agreement for 16 themes (0.72).

Slide 14

...and Compared Themes to Behaviors Captured in CAHPS Survey Items

• Core CAHPS items:
  • Doctor-patient communication.
• Supplemental CAHPS items:
  • Health information and promotion.
  • Shared decisionmaking.
  • Patient-centered medical home items.
  • Cultural competence.
  • Health literacy.
  • Health information technology.

Slide 15

Presentation Outline

• Why focus on doctor-patient communication?
• Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective?
• Feedback from high-performing physicians.
• Summary and implications.

Slide 16

Physicians Identified 16 Behaviors that Support Communication

• 9 mentioned by more than 7 of 11 physicians.
• 6 of 9 most frequently mentioned behaviors captured in current CAHPS items.
• 3 behaviors identified for further survey item development.

Slide 17

Nine Behaviors Mentioned Frequently (n = 11 physicians)

1. Employ office staff with good people skills (91%).
2. Use non-verbal communication (82%).
3. Involve office staff in communication with patients (82%).
4. Spend enough time with patients; don't act hurried (73%).
5. Listen carefully (73%).
6. Provide clear, simple explanations (64%).
7. Greet patients by shaking hands, introducing self (64%).
8. Ask social or personal questions; track and follow this information (64%).
9. Devise action plans/next steps at each visit (64%).

Slide 18

CAHPS Captures Six of the.Nine Behaviors.

1. Employ office staff with good people skills.
2. Use non-verbal communication.
3. Involve office staff in communication with patients.
4. Spend enough time with patients; don't act hurried.
5. Listen carefully.
6. Provide clear, simple explanations.
7. Greet patients by shaking hands, introducing self.
8. Ask social or personal questions; track and follow this information.
9. Devise action plans/next steps at each visit.

Slide 19

Presentation Outline

• Why focus on doctor-patient communication?
• Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective?
• Feedback from high-performing physicians.
• Summary and implications.

Slide 20

Summary of Findings

• CAHPS survey items capture many of the communication behaviors most frequently mentioned by high performing physicians.
• Three aspects of communication are not captured by current CAHPS items:
  • Non-verbal communication.
  • Greeting the patient.
  • Tracking personal information about the patient.

Slide 21

Possible Next Steps

• Testing and developing additional patient experience-of-care measures:
  • Nonverbal communication.
  • Physician greeting and introducing self to patient and family.
  • Physician tracking of personal information about patient.
• Further research is important to understand additional value and association with other patient experience measures.

Slide 22

Image: The RAND HEALTH logo is shown.