Editor’s note: In this excerpt from the HCPro book Beyond CAHPS: A Guide for Achieving Patient- and Family-Centered Care, author Janiece Gray, MHA, BSW, CPXP, and contributor Kevin Campbell, both of DTA Associates, discuss sources of patient experience data and supporting technology.
One of the first things to consider with regard to data is the various sources of patient experience data within the organization. When it comes to various aspects of the patients’ voices to project, one of the best places where these patient comments can be found is the open-ended questions on any survey.
In addition to comments, there is plenty of quantitative data related to the patient experience. Most organizations, regardless of sector (long-term care, home health, emergency department, ambulatory surgery centers, clinics, hospitals) have some kind of survey related to their patients’ experiences. In many cases, there are requirements about this—HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), CG (Clinicians and Groups) CAHPS, HH (Home Health) CAHPS, and ICH (In-Center Hemodialysis) CAHPS. One of the biggest considerations for organizations is whether to survey the minimum required both in terms of sample size and frequency. For meaningful improvement, it’s often necessary to go beyond these minimum requirements or to augment them with other tools and technology. In other organizations, even those without a requirement for a survey, most have determined the need for some component of measurement and pulse of their patients and families or residents’ experiences. Many organizations that are “early adopters” in using the tools before they become required are far ahead in terms of performance when reporting becomes a mandate.
Types of measures
There are three types of outcomes used to help judge success on a project (Institute for Healthcare Improvement, n.d.). These measures are:
The outcome measure is really your target for improvement. For example, in patient experience, the survey results that are publicly reported are used to calculate value-based purchasing as the outcome measure.
The balancing measure is the metric that you look at to make sure that improvement in one area doesn’t negatively impact another. If we are asking nurses to do a bedside shift report, we don’t want to negatively impact overtime. In this case, overtime would be the balancing measure.
The process measure is specific to some of the processes or strategies that lead to success in the overall outcome. If the communication composite is the outcome, some process measures may include specific strategies around use of care boards in the rooms or rounding on patients.
Most often, the survey data or outcome measure is what is focused on in the organization.
Our first exposure to patient experience was in working with an organization where the organization was its own vendor for its required surveys. This involved following the specifications from CMS related to sending surveys, opening the mail, date stamping, and scanning in the surveys within a certain time frame. It also involved numerous quality checks of the equipment, etc. As we worked through the need for improvement in the organization, we determined that 90% of our time was being spent identifying the patients, sending the surveys, getting the surveys, scanning the surveys, and reporting the surveys. After all that, only 5%–10% of the time was left for understanding the data that we had and making steps toward meaningful improvement.
Consequently, we decided to outsource our data to a survey partner. We incorporated a patient in the request for proposal (RFP) process and he, together with an interdisciplinary team of leaders, helped us decide on which partner to use. This process occurred very quickly with a six-week implementation timeline.
For the required surveys, there are many quality checks and various other requirements that are arduous for an organization to manage themselves. We definitely advocate for outsourcing this function. However, simply turning this over to a survey vendor does not eliminate the need for leaders within the organization to know what is going on with the data.
When we led the first RFP process to outsource the surveying, we carefully chose the language of “survey partner,” moving away from the use of the term “vendor.” It sounds like semantics, but it’s actually deliberate language aimed at creating a partnership that is essential to success and improvement. If you don’t have a partnership with your survey company, you need to forge one. The reason this is so essential is that you and the teams that you work with (the physicians in particular) need to trust the data. We’ll talk about some of the challenges inherent to patient experience data in general, but you need not add any concerns regarding data quality to those.
The grass is always greener
In our work today at DTA, we are often asked to come in and help organizations lead their own RFP process as they explore switching companies for their surveys. For this reason, we try to stay neutral with regard to any endorsement of one vendor over another. What we can tell you is this: In countless organizations that we work with on improvement, we will hear complaints about their survey vendor. At this point, we’ve heard complaints about pretty much every company out there. These complaints generally center on certain themes:
> Data quality
> Frequent turnover of account reps assigned to the organization
> Lack of timely responses to questions or concerns
> Feeling like a big fish in a small pond, or a small fish in a big pond (mostly in regard to benchmarks and time and attention from the survey company)
> Survey mode adjustments (transition from mail to email, or to phone or Interactive Voice Response, etc.)
The fact that we’ve heard these complaints about basically every survey company out there leads us to counsel organizations that when they are looking to make a switch, the grass is always greener on the other vendor’s side of the fence. There is a cost to switching vendors—mostly on the backs of your report writers, data warehouse team, and data analysts—but also in terms of retraining the organization on how data is displayed, how reports can be retrieved, etc. That being said, sometimes that’s the only way to start fresh and realize the goal of forming a new survey partnership.
Supplement to aid in improvement
Regardless of your vendor partner, we encourage organizations to take advantage of their proprietary survey items. On the required surveys (HCAHPS, CG CAHPS, HH CAHPS, etc.), organizations have the option to add some key items to the survey. This makes many people uncomfortable about the length of the survey. We hear that, but we still encourage adding even up to 10 supplemental items that can help to inform your improvement. For example, if you’re focused on communication, then items about courtesy and respect, listening carefully, and explaining things can only tell you so much. There are much more comprehensive items that can drill down into specific areas of focus.
Consider this example for the Communication with Doctors composite within HCAHPS. We love this because it really helps to inform the greater areas of detail within communication. Most every vendor has their own proprietary survey items to add in addition to your CAHPS-required surveys. By going beyond the compulsories, you’re able to start to connect the dots to really lead to collaborative improvement. This can also help identify and track some of the “hidden” composites that can impact CAHPS performance.
Augment with appropriate technology to inform
Regardless of the survey tool that you use to meet the current or coming requirements for your service area/organization, it is often helpful to augment it with additional sources of data. While the survey tool may be your outcome metric, there are many other ways to get some process metrics for the organization. Another reason that organizations will use additional sources of technology to inform their work is to the timing of the responses. The key is to be careful that questions asked while a patient is still an inpatient, for example, do not resemble the questions on the HCAHPS survey. Specifically, “HCAHPS should be the first survey patients receive about their experience of hospital care.” CMS is very serious that organizations adhere to this (2009).
That being said, there still ways you can get more real-time feedback from patients. A great way to do this is to spot-check an improvement. Let’s say that you implemented a new care board in the emergency department and you want to know how it’s being used and how patients perceive it. Finding a way to ask questions about that on a quick kiosk or in room tablet technology for a few weeks or months can help you to see how your improvement is progressing.
We like to stay neutral with regard to these technology companies as much as with the survey companies. In this space, there are more and more companies with varying technology popping up all the time. There are some excellent products out there that we have used in various organizations, so you have many good options to consider.