Executive Summary:
- Definition of patient-centered care from Crossing the Quality Chasm
- Healthcare is focusing on patient-centered care as evidenced in print, support by payers and growth in patient-centered medical home
- Providers can and should measure how patient-centered they are
- Benchmarks and surveys are two tools that can be used to measure success at being patient-centered
- Providers should act upon the data they collect
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Is patient-centered care important? If it is, can it be measured and can the results of the measurements be used to create plans that can be executed to provide better care for patients? My answer is “yes” to all of these. Let me explain why.
Before we proceed, let me share what I believe to be a good definition of patient-centered care. Taken from the Institute of Medicine’s Crossing the Quality Chasm it is “Healthcare that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care”.
I have found this definition being used in many healthcare settings. It is used as a starting point for discussions in two articles in the January issue of Connexion magazine of the Medical Group Management Association; the articles are “Patient-centered care” and “the State of Medical Practice”. Besides the focus on patient-centered care found in print such as Crossing the Quality Chasm and Connexion magazine along with numerous other articles in magazines such as Health Affairs, payers such as Aetna and Wellpoint are focusing on it through their support of patient-centered medical homes. Most PCMH’s are structured according to the Agency for Healthcare Research and Quality’s medical home model; they do focus on implementing the definition of patient-centeredness as used in Crossing the Quality Chasm. Many others are focused on the PCMH and being patient-centered. CMS has a PCMH pilot program; the University of Michigan Healthcare Group is a part of the pilot. In Michigan Priority Health and Blue Cross Blue Shield of Michigan support variants of the PCMH. Two of the major hospital groups in West Michigan (where I live) have adopted the PCMH model. In fact, my own primary care physician’s group has adopted the model.
Let me add yet another argument why being patient-centered is important. I have talked to numerous physicians who wish that patients would take more responsibility for their well-being. I have read the same in many physician posted blogs on KevinMD.com. Nurses I know also support this position. Being patient-centered does require that the patient take responsibility for his or her own care as much as they are able. If a patient is involved in decisions about his own care, then he and his family are also responsible for the successful implementation of his care plan to the extent that they are able.
If patient-centered care is important, as I believe that I have shown, then it is necessary for providers to measure their success with this strategy at their practice site. By measuring one’s success at being patient-centered one can use the resulting data to improve the delivery of care to his or her patients. One way to measure being patient-centered is through benchmarks. For instance, a practice can measure how quickly patients with acute care conditions can been seen by a physician. Practices that are certified as PCMH’s have a 98% success rate in seeing such patients on the same day or within two days, according to data in the January edition of Connexion magazine.
Another source of data for measuring success in being patient-centered is by patient satisfaction surveys, if they are constructed correctly. One such survey is HCAHPS, a survey being used by Medicare to rate hospitals on the quality of the care that they provide. HCAHPS accounts for 30% of the quality score that hospitals receive from CMS; the quality score is being used as a measure to determine whether hospitals receive a performance bonus or are penalized in reimbursements. Starting in 2015 CMS will measure physician quality with a CAHPS survey.
There is much misunderstanding, I believe, about HCAHPS. For instance, an ED nurse told me the story of a Medicaid patient who came in one morning to get Tylenol with codeine for her menstrual cramps. After much discussion with the physician about why she did not visit her local pharmacy for over the counter drugs, he gave her a prescription for the drug. He did so because administration had stressed to him the importance of meeting the demands of patients so that the hospital’s HCAHPS scores would be good. It seems that administrators and some physicians are wary of upsetting patients because this could affect their scores on the survey. It is clear to me that the administration was focusing on scores and not the patients.
In a recent article on the New England Journal of Medicine’s website, “The Patient Experience and Health Outcomes”, authors Matthew Manary, et al. cleared up many of the misperceptions about this particular survey and included some comments on good survey design regarding being patient-centered. Critics of the survey contend that the survey merely captures “how happy” the patient is with his or her care, as in the story above. The authors explain that the initial questions focus on the quality of communication between patients and caregivers, whether physician or nurse and not on “happiness”. The answers of patients are strongly correlated with health outcomes.
Another criticism of HCAHPS is that patients rate their experience based upon their health outcomes regardless of the quality of care. Research by the authors and others has shown that this is not true, that patients’ responses are reflective of some aspects of quality that are otherwise difficult to capture.
A third criticism of the survey is that it is a measure of patients’ wishes regarding their care which may not be founded in good practice. The authors state this is not so. Because patients tend to trust their caregivers, they are willing to listen to physicians’ and nurses’ recommendations about what are the best care choices.
In my opinion and based upon my experience in survey design I believe that the authors have demonstrated that the HCAHPS is a good instrument to measure being patient-centered. If used soon after a care event it accurately captures the quality of care provided for the given event. Providers who construct their own surveys to measure patient satisfaction can use it as a guide to develop reliable surveys.
As I stated earlier, it is important to use the data gathered from patient satisfaction surveys as a guide to improve the delivery of service and care. I am involved in a research project that is working to provide continuously better outcomes for our clients. Our work group uses the data analysis that I provide to help them improve the delivery of service; the focus of the research is how to help our clients become better at managing their finances. The data analysis is one component of our effort to become a continuously learning organization, as the Institute of Medicine encourages in a recent publication, Best Care at Lower Cost. We are increasingly successful in meeting the goals of the research.
Clearly, the concept that being patient-centered is an important component of effective care is being advocated today in many places, in print, in research, in PCMH’s and by payers. Providers who adopt this strategy for providing effective care should measure their success in doing so, whether by using benchmarks, surveys or other quality measures. Once the results of the measures are analyzed, I believe that it is very important to use the data to provide ever better care for the patient, often at lower cost.