Patient Satisfaction Surveys: How to measure the patient experience

In order for health care to be effective, it is important for all of us (as patients) to engage with the healthcare delivery system in an active way. This can be a challenge if that delivery system doesn’t work well, is not focused on the overall patient experience, or is preoccupied with its internal machinations rather than on its most important goal – to deliver high quality service tailored to our individual needs.

Often, when we encounter the healthcare system, it is at a time when we face fear or uncertainty – we are ill, or are facing unknown recommendations (even for wellness surveillance) that we’d rather not deal with. The healthcare system can seem overwhelming, daunting, impersonal, and foreign. The difference between compliance with the recommendations from healthcare professionals and non-compliance depends heavily on our experience with our encounters. This has been measured in the past as “patient satisfaction” (now more commonly referred to as “patient experience”), often through post-encounter surveys.

The role of surveys
This kind of measurement of patient experience is increasingly becoming important as we develop novel, more coordinated delivery methods within health care, and as our technological ability to conduct such surveys becomes greater. A sentinel article in the British Medical Journal in 1999 highlighted the increasing importance of patient surveys, given that sound survey methods now exist, and can guide improvement in healthcare delivery.

As we move away from a fee-for-service dominated way of paying for health care, and toward one that values performance and outcomes more heavily, using patient surveys is an important domain of measuring such performance. In areas where performance-based compensation has been implemented, such as in California’s Integrated Healthcare Association (IHA) program of supplementing the payment for HMO care to groups with a pay-for-performance “bonus” for delivering measurable quality, “patient experience” is one of the domains that is measured.

As we see the emergence of integrated delivery networks, with Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) being the current emerging forms for this, patient surveys that gather feedback on patient experience are part of the “performance” for which these new organizations are rewarded.

Components of patient experience
Patient engagement can be thought of as having several factors: (1) the in-office experience, (2) on-line access, and (3) coordination of care between different health settings. Let’s look at each of these, briefly.

The in-office experience. There are several elements that influence a patient’s assessment of their experience with a medical office. First is the establishment of a good interpersonal rapport with the clinician – there are best-practices that can help clinicians use their EHRs as resources, rather than “the elephant in the room,” in order to connect person-to-person during the clinical visit.

Second is the establishment of good office workflow, so that the patient can move through a visit and have every station, every part of the practice, work seamlessly together. That means things like short wait times, pre-knowledge of what the reason for the visit is, already having possibly-required authorizations (if needed) in hand when they are necessary, etc.

And third, having an open schedule approach, which balances the needs of scheduled appointments (routine follow up for chronic conditions scheduled several months ahead) and the needs of same-day urgent visits. Multiple approaches to open scheduling have been explored and described in the literature.

On-line access. Another domain that affects a patient’s experience in interacting with the healthcare system is the ability to access one’s own health information on-line. Connected patient-facing web portals are a feature of many modern EHRs (a connected PHR-EHR), which allows (at a minimum) the review of one’s problem lists, medications lists, allergies, immunizations, lab tests and upcoming appointments.

Two-way communication across these channels are also an emerging capability, so that patients can contact the practice in a secure way – these queries tend to be in lieu of phone calls (not in lieu of actual visits). Usually such communication is about refill requests, interpretation of lab results, and sometimes about health complaints. Payment models that facilitate such communication, and remove barriers to it, are critical in order for this to really flourish.

On-line access to health education resources is also possible. Patients seek health information on-line regardless, but the clinical office can play a big role in curating such content and providing a trusted source for more personalized health education.

Coordination between health settings. This is a big driver of overall satisfaction with one’s health care experience – does the delivery network function in a cohesive way, or is it disjointed? Does the patient have to re-enter the same information about past history with every office visited? Does the referral recipient know why the patient is there, and what tests or medication trials have already been done? A robust collaboration platform for facilitating such “systemness” is one of the big tasks for health IT in this next phase.

Who does the measuring?
Traditionally, health plans have evaluated clinical performance of physicians based on claims data, as well as surveys they send out to their members (usually on an annual basis). “Report cards” of performance are then created, and sometimes published (internally and publicly). This has been the case for a few decades.

As health care has become more organized, and organizations of physicians and hospitals have taken on the responsibility to manage a given population, then those organizations have done some of the surveying themselves – this brings the measurement one step closer to the point of care. IPAs and medical groups have done this for HMO management, where delegated models have functioned (such as in California). Upcoming new ways of delivering coordinated care, such as PCMHs and ACOs, are also places where surveying patient experience will take place. In fact, it is required for these organizations to conduct such patient surveys.

Another place where patient satisfaction is measured is directly from consumers. Numerous web sites have sprung up, entirely outside the domain of traditional health care, which rate satisfaction with individual clinicians. Such consumer-driven public rating is a fact of life in most economic sectors, and is becoming a fact of life in health care as well.

Most directly, EHRs are now developing ways to send patient satisfaction surveys after each visit, so that the clinical practice can directly assess their patients’ experience in a more direct and real-time way. Annual surveys done by health plans, ACOs or groups are more arms-distant, and more infrequent, so that changes in how a clinical practice functions cannot be changed that quickly. But if more-immediate feedback from patients becomes a routine part of clinical care (after-visit surveys, generally by email), then there is the opportunity for practices to improve in real-time. This approach holds the most promise for affecting patient satisfaction with their care than any other to date, and is something we will see built into EHRs in the near future.

Doing well matters
Pulling all this together, we can see that measurement of patient experience is increasingly being used, and is a driver of performance-based compensation. It is important as part of bundled payments to organizations responsible for population management.

This can be done well, if attention is paid to best-practice habits. Modern health IT is now emerging that will offer easy-to-implement tools to measure patient experience much more real-time, and closer to the source. This kind of immediate feedback is a powerful driver of improving the quality of the health care experience at the point of care – in fact, it could be argued that nothing but practice-generated surveying (and not more distant surveying from health plans or even groups) is what is needed to measurably affect change.