Measuring Hospital Care from the Patients' Perspective: An Overview of the CAHPS® Hospital Survey Development Process

Objective. To describe the developmental process for the CAHPS^® Hospital Survey.
Study Design. A pilot was conducted in three states with 19,720 hospital discharges.
Methods of Analysis. A rigorous, multi-step process was used to develop the CAHPS Hospital Survey. It included a public call for measures, multiple Federal Register notices soliciting public input, a review of the relevant literature, meetings with hospitals, consumers and survey vendors, cognitive interviews with consumer, a large-scale pilot test in three states and consumer testing and numerous small-scale field tests.
Findings. The current version of the CAHPS Hospital Survey has survey items in seven domains, two overall ratings of the hospital and five items used for adjusting for the mix of patients across hospitals and for analytical purposes.
Conclusions. The CAHPS Hospital Survey is a core set of questions that can be administered as a stand-alone questionnaire or combined with a broader set of hospital specific items.     

Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences

Background Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts. Objectives To qualitatively explore acute care consumer perceptions of patient safety. Design and methods Thirty‐nine individuals with a recent overnight hospital visit participated in one of four group interviews. Analysis followed an interpretive analytical approach. Results Three basic themes were identified: Communication, staffing issues and medication administration. Consumers associated care process problems, such as delays or lack of information, with safety rather than as service quality problems. Participants agreed that patients need family caregivers as advocates. Conclusions Consumers seem acutely aware of care processes they believe pose risks to safety. Perceptual measures of patient safety and quality may help to identify areas where there are higher risks of preventable adverse events.     

Discharge decision-making with older people: The influence of the institutional environment

Background/Aim:  Occupational therapists often participate in decision-making about postdischarge accommodations. This paper presents the findings of a study that identified and explored institutional factors influencing discharge accommodation decision-making with older people, from the perspective of occupational therapists.
Methods:  Qualitative, semistructured, face-to-face interviews were conducted with 10 occupational therapists. Interviews were recorded, transcribed, coded and analysed for the presence and emergence of themes.
Results:  Decision-making processes were influenced by the institutional environment. The medical model and pressure for fast decisions seemed to impede client-centred processes in acute settings.
Conclusions:  When possible, decision-making about long-term care needs to occur in community or longer-stay rehabilitation settings that allow time for negotiated client-centred processes.     

Validation of 2 New Measures of Continuity of Care Based on Year-to-Year Follow-up With Known Providers of Health Care

PURPOSE

In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP).

METHODS

Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients’ responses.

RESULTS

Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33–3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06–2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11–2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10–2.00). KPC-PP was not significantly associated with any of the survey measures.

CONCLUSIONS

The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions.     

Patient perceptions of patient‐centred care: empirical test of a theoretical model

Aim

Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient‐centred care using patient perception survey data.

Background

Patient‐centred care is one of the Institute of Medicine''s objectives for improving health care in the 21st century. Patient interviews conducted by the Picker Institute/Commonwealth Fund in the 1980s resulted in a theoretical model and survey questions with dimensions and attributes patients defined as patient‐centered.

Method

The present study used survey data from patients with overnight visits at 142 U.S. hospitals.

Results

Regression analysis found significant support for the theoretical model. Perceptions of emotional support had the strongest relationship with overall care ratings. Coordination of care, and physical comfort were strongly related as well.

Conclusion

Understanding how patients experience their care can help improve understanding of what patients believe is patient‐centred, and of how care processes relate to important patient outcomes.     

Functional Status Across Post-Acute Settings is Associated With 30-Day and 90-Day Hospital Readmissions

ObjectiveTo examine the association between cocalibrated functional scores across post-acute care settings and the subsequent risk of hospital readmission.DesignRetrospective cohort study.Setting and ParticipantsWe analyzed 781,021 fee-for-service Medicare beneficiaries discharged to either inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHA) after an acute hospital stay for stroke (N = 143,277), lower extremity joint replacements (512,577), and hip/femur fracture (125,167) between January 1, 2013, and August 31, 2014.MeasuresFunctional items from IRF-PAI, MDS, and OASIS were categorized into self-care and mobility domains. We cocalibrated admission functional scores across post-acute settings and divided scores into 4 functional levels using quartiles (Q1-Q4, with Q4 representing the most independent function). The primary outcomes were 30-day and 90-day hospital readmissions (yes/no) after an initial post-acute stay.ResultsPatients who were more dependent in self-care and mobility at the initial post-acute setting were significantly more likely to experience hospital readmission [eg, hazard ratios of 30-day readmission in stroke: 1.54 (95% confidence interval [CI] 1.47-1.61), 1.18 (95% CI 1.14-1.23), and 1.12 (95% CI 1.08-1.16) for Q1, Q2 and Q3, compared to Q4]. We found similar results for risk of 90-day hospital readmission across impairment conditions.Conclusions and ImplicationsPatients who were more functionally dependent at the initial post-acute setting had a higher risk to readmit to the hospitals after discharging from the post-acute setting for 30 and 90 days, compared with patients who were more functionally independent. This finding is consistent across impairment conditions and post-acute settings. Future research should determine effective strategies of maintaining and facilitating functional performance across post-acute settings to optimize long-term patient outcomes.     

Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff

PURPOSE We wanted to understand the views of patients and clinicians on the central concept of healing and to identify major facilitators of and barriers to promoting healing in primary care.METHODS We undertook a qualitative analysis of focus group discussions. Participants were drawn from primary care clinics of a large, integrated, health care system in Washington State in 2005. Nine focus groups included 84 participants: 28 patients, 23 primary care physicians (19 family physicians), 20 registered nurses, 11 licensed practical nurses, and 2 medical assistants. Randomly sampled established patients were aged from 21 to 65 years; 71% were female.RESULTS We found remarkable concordance across focus groups and among types of participants in the definition of healing: Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional, and spiritual dimensions. The key themes are as follows: (1) healing is multidimensional and holistic; (2) healing is a process, a journey; (3) the goal of healing is recovery or restoration; (4) healing requires the person to reach a place of personal balance and acceptance; and (5) relationships are essential to healing. Factors that facilitate healing help build relationships, improve communication, and share responsibility between the patient and clinician. Major barriers are logistical factors that limit high-quality time with healing professionals.CONCLUSIONS Patients and health care team members share a vision of healing and agree on ways to enhance the process in primary care.     

Approaches to reducing the most important patient errors in primary health‐care: patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients’ contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants’ suggestions revealed the content of four inter‐related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from ‘individualised community care’. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health‐care.     

Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007

PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions.METHODS We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction.RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age.CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.     

Rethinking quality in the context of persons with disability.

OBJECTIVE: To review the current health services literature related to quality of care for persons with disabilities and to highlight the need for a unique framework for conceptualizing quality and patient safety issues for this population. DESIGN: Drawing on quality measurement theory, we formulate a multi-dimensional model of quality of care for persons with disability. This model is then used to identify and summarize findings from existing health services research that relate to the quality, of care for persons with disability. STUDY SELECTION: We searched MEDLINE and other databases for primary research and review articles containing the phrases 'quality of care', 'patient safety', 'access', 'patient experience', and 'coordination of care' in conjunction with the words 'disability' or 'impairment'. RESULTS: A review of health services research suggests several potential issues in the areas of clinical quality, access, client experience, and coordination. Physical barriers, transportation, communication difficulties, and client and provider attitudes present barriers to receiving appropriate client-centered care. Communication difficulties between provider and client may increase risk for accidental injury and decrease the quality of the client experience. Frequent contact with the health care system and the complexity of an individual's situation also increase the risk of accidental injury. Coordination, the 'lubricant' that facilitates links for all areas of quality for a person with disability, presents the most significant opportunity for improvement, because multiple medical and social providers are typically involved in the care of individuals with disabling conditions. CONCLUSION: Health care providers need to embrace a multi-disciplinary approach to quality to meet the needs of persons with disabilities. Funders and purchasers need to provide flexibility in funding to enable a comprehensive primary care approach, while health service researchers need to adopt a broad view of quality to capture issues of importance for persons with disabilities.     

An empirical study of patient participation in guideline development: exploring the potential for articulating patient knowledge in evidence‐based epistemic settings

Background

Patient participation on both the individual and the collective level attracts broad attention from policy makers and researchers. Participation is expected to make decision making more democratic and increase the quality of decisions, but empirical evidence for this remains wanting.

Objective

To study why problems arise in participation practice and to think critically about the consequence for future participation practices. We contribute to this discussion by looking at patient participation in guideline development.

Methods

Dutch guidelines (n = 62) were analysed using an extended version of the AGREE instrument. In addition, semi‐structured interviews were conducted with actors involved in guideline development (n = 25).

Results

The guidelines analysed generally scored low on the item of patient participation. The interviews provided us with important information on why this is the case. Although some respondents point out the added value of participation, many report on difficulties in the participation practice. Patient experiences sit uncomfortably with the EBM structure of guideline development. Moreover, patients who develop epistemic credibility needed to participate in evidence‐based guideline development lose credibility as representatives for ‘true’ patients.

Discussion and conclusions

We conclude that other options may increase the quality of care for patients by paying attention to their (individual) experiences. It will mean that patients are not present at every decision‐making table in health care, which may produce a more elegant version of democratic patienthood; a version that neither produces tokenistic practices of direct participation nor that denies patients the chance to contribute to matters where this may be truly meaningful.     

英国改善患者体验指南解析

改善人民群众看病就医体验,是深化医药卫生体制改革的必然要求和最终目标,实施健康中国战略对增强人民群众获得感又提出了新的要求。从国际经验来看,要实现"以患者为中心"的价值医疗,改善患者体验是一个很好的切入点。英国是国际上较早重视改善患者体验的国家,除了像大多数国家那样通过改进医疗服务质量来改善患者体验之外,还发布了专门的改善患者体验指南。文章对英国改善患者体验指南的内容进行了详细介绍,并提出了相应建议,以资为我国患者体验相关研究和政策制定提供借鉴。