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Delivering Value by Focusing on Patient Experience

Paula Chatterjee, MD, MPH; Thomas C. Tsai, MD, MPH; and Ashish K. Jha, MD, MPH
As reimbursement shifts toward value-based payments, patient experience measures should play a pivotal role in how we measure quality.
ABSTRACT
 
The use of patient experience as a quality metric in healthcare remains controversial. Clinicians have expressed concern that incentives focused on patient experience may lead to lower quality care. However, empirical evidence from the United States and abroad suggests that hospitals and ambulatory care providers with higher patient satisfaction scores also perform better on clinical process and outcome measures. While it may be that high-performing providers simply have more resources to devote to both patient experience and the technical aspects of care, we suspect that these providers’ performance is also driven by a conscious commitment to quality. As the country shifts toward new payment models, we should encourage this type of commitment to quality. Perhaps most importantly, improving the patient experience will build trust in the healthcare system, guard against withholding of services in the face of changing provider incentives, and promote collaboration between clinicians and patients. Therefore, patient experience measures should play a critical role in how we judge high-quality, value-based care.

Am J Manag Care. 2015;21(10):735-737
The notion that a patient’s experience with healthcare should be a key component of how we gauge healthcare quality is a relatively new phenomenon. While strands of consumerism have existed in American medicine for generations, the shift toward formally evaluating and, subsequently, valuing patients’ perceptions of their care has been a result of the widespread adoption of validated tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS). Although patient experience has started to serve as the basis for public reporting and pay-for-performance, its use for judging quality has been met with a remarkable amount of resistance. As the US healthcare system refocuses on value, deciding how big of a role—if any—patients’ perspectives should play in how we define value will become a crucial question for policy makers and clinicians.
 
The Controversy
The use of patient-reported experience as a quality metric in healthcare is controversial in that critics contend that its inclusion as a key measure is driving institutions to focus on the wrong priorities, thereby encouraging them to behave like hotels instead of care delivery organizations.1,2 The increasing focus on these measures—by which we evaluate and pay for health care—may shift provider attention away from the delivery of technically effective care, and instead focus on services that are less clinically important. Critics further argue that shifting incentives may even reduce the quality of care when patient demands are diametrically opposed to good clinical practice, such as prescribing antibiotics to a patient with viral syndrome or narcotics to a patient at high risk for opiate dependence.
 
Advocates for patient experience measures counter that the metrics are important in and of themselves: they are not “soft” service measures that can be addressed through fancier hospital lobbies or better food. Rather, they measure critical components of care that only patients can report, such as whether pain was addressed effectively or if patients received clear communication from physicians and nurses. In an industry where the patient should be the primary focus, the content of their experiences can help clinicians to better mobilize around patient needs.
 
The Evidence
Although the debate has been lively and important, it has largely been driven by anecdotes. There is, however, a growing body of empirical work that should serve as the basis for how patient experience fits into notions of high-value care. These data should guide our approach to incorporating patient experience measures into global assessments of the quality of care delivered.
 
In a national study of US acute care hospitals, the institutions with the highest adherence to clinical guidelines and evidence-based processes of care also had substantially better scores on patient experience metrics compared with hospitals with lower levels of adherence to guideline-based care.3 These patterns apply to outcome measures as well, since hospitals with the lowest risk-adjusted mortality rates for acute myocardial infarction tend to have the highest patient experience scores.4 There is a similar pattern for surgical care: hospitals that score the highest on patient experience metrics have, on average, lower mortality rates, lower readmission rates, and greater adherence to process measures for common major surgical conditions.5 Similar studies have been replicated in ambulatory-care practices and in healthcare settings outside the United States, such as in the United Kingdom.6 High-quality hospitals and physicians appear to focus on not only technical excellence, but also on how their care is perceived by patients. The totality of the evidence is strong and reasonably consistent: there need not be any tradeoff between delivering technically excellent care and delivering care that is attentive to the needs and expectations of the patient.
 
What explains these relationships between patient experience and clinical quality? First, some healthcare organizations simply have more resources than others. These additional resources may allow for more staff to be hired, which would then provide physicians with more time to explain clinical decisions to patients and allow nurses to respond more quickly to patient needs. These organizations, simply by having more resources, may give physicians and nurses the opportunity to be both effective and patient-centered in ways that patients perceive as important. A closely related, but different, explanation is that high-quality institutions prioritize and closely monitor not only the technical aspects of quality such as adherence to evidence-based guidelines of care, but also the more interpersonal components such as those measured by patient experience metrics. In this type of institution, high performance in these 2 areas is driven by intention, not as a by-product of having more resources. These organizations might pay closer attention to a broad set of activities that ensure that patients have both good outcomes and a positive experience. Monetary resources may facilitate reaching this goal, but it need not be dependent on being well-resourced; instead, we suspect that the strong, consistent relationship between patient experience and technical measures of quality likely reflects both of these mechanisms. Performance on patient experience and clinical measures may be complementary by nature, or the inputs required to excel in both may be one and the same.
 
Beyond their intrinsic importance and their complementarities with other quality measures, there is 1 more important reason for including patient experience in value-based payment programs: holding physicians and hospitals accountable for patient experience builds trust in the healthcare system from the perspective of the patient, guards against the withholding of vital services, and promotes collaborative practice between clinicians and patients. When patients have a better experience, they are more likely to adhere to treatments, return for follow-up appointments, and engage with the healthcare system by seeking appropriate care.7 As healthcare systems are asked to take a more “global” perspective on patient care, focusing not only on the episode of care, but also on the continuum of the clinical relationship, these metrics will become increasingly important.
 
Patient Experience and Value-Based Payments
Given the obvious face validity of patient experience measures and the evidence that, for most healthcare organizations, there is no tradeoff between patient experience and technical measures of quality, patient experience scores should be a part of any value-based payment program. CMS recently announced the launch of Hospital Compare Star Ratings, based on HCAHPS, in order to help patients to better choose hospitals and understand the quality of inpatient care. Beyond public reporting, policy makers have signaled that over the next several years, the majority of Medicare payments will be tied, at least in part, to value-based payments.8 With an established link to technical quality, patient experience metrics should play a critical role in how we judge high-quality, value-based care.
 
As patient experience takes on a larger role, measurement tools may need to adapt to changing practice environments and patient needs. Beyond the HCAHPS survey, clinicians and policy makers will need metrics that capture real-time patient experience data and offer the opportunity for feedback that allows for more active iteration of practices. The scoring of these metrics will also require refinement and flexibility in order to ensure that we are attuned to the idea that different patients may value certain aspects of their experience more than others.

Conclusions
Given the evidence, the question should no longer be whether to use patient experience scores to assess the quality of healthcare services, but rather, how much to prioritize it among other emerging measures of value-based payment. For good clinicians, these metrics should confirm their superior performance; for the broader healthcare community, the focus should be on how to best assess, understand, and use these data in ways that will help all clinicians to provide more responsive care to patients. Paying attention to patient experience is not just good policy—it’s good medicine.
Author Affiliations: Department of Medicine (PC, AKJ) and Department of Surgery (TCT), Brigham and Women’s Hospital, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (TCT, AKJ), Boston, MA; and VA Boston Healthcare System (AKJ), Boston, MA.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PC, TCT); drafting of the manuscript (PC, TCT); critical revision of the manuscript for important intellectual content (PC, TCT, AKJ); and supervision (TCT, AKJ).

Address correspondence to: Ashish K. Jha, MD, MPH, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: ajha@hsph.harvard.edu.
REFERENCES
 
1. Robbins A. The problem with satisfied patients. The Atlantic website. http://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/. Published April 17, 2015. Accessed September 2015.

2. Rosenthal E. Is this a hospital or a hotel? The New York Times website. http://www.nytimes.com/2013/09/22/sunday-review/is-this-a-hospital-or-a-hotel.html?_r=0. Published September 21, 2013. Accessed June 11, 2014.

3. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921-1931.

4. Glickman SW, Boulding W, Manary M, et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;3(2):188-195.

5. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261(1):2-8.

6. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1).

7. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213-220.

8. Burwell SM. Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372(10):897-899. 
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