Patient satisfaction surveys can be a valuable tool to measure the patient’s perspective of providers and staff of medical facilities. Using these tools wisely is the key to raising the bar on service excellence, which should be the goal of everyone in the healthcare industry.
The perception of patients is what drives patient satisfaction; therefore, it is extremely important to explore the factors that the patient values and implement changes if necessary based on those findings.
HCAHPS and CG-CAHPS
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures 27 items: 18 of which include critical aspects of the patient’s experience in the hospital and involve communications with doctors and nurses, as well as responsiveness of the staff. It evaluates the cleanliness and quietness of the setting, medication requests and questions that relate to likelihood of recommending the hospital.
Unlike HCAHPS, the CG-CAHPS (CAHPS Clinical & Group Survey) is the standard tool to measure a patient’s experience in the ambulatory setting. The Centers for Medicare & Medicaid Services (CMS) issued the final rule on Nov. 16, 2012, confirming implementation for the Physician Quality Reporting System (PQRS). This requirement was for practices that have more than 100 professionals. Accountable Care Organizations (ACOs) and Medicare Shared Savings Program ACOs are required to participate in data collection as part of the CG-CAHPS program.
So, who gets these surveys? For the HCAHPS, a sampling of patients receive the survey between 48 hours and six weeks after being discharged. The criteria for eligibility is that the patient is 18 years or older at time of admission, he or she must have been an inpatient for at least one night, cannot be admitted for a psychiatric event and lastly, the patient must be alive at discharge. Most hospitals are required to collect at least 300 surveys, and they must be sent out continuously, either ongoing or at the end of the month. With an average of only 18% of the surveys being completed and returned, collecting even the minimum required number of surveys in a year can present a challenge to some facilities.
Most patient satisfaction surveys, including CG-CAHPS, focus on the experience of the patient in the ambulatory setting. After a visit to a primary care provider or specialist, the patient may receive one of these surveys. If he or she has signed up for a patient portal, it will probably be delivered electronically. If not, a paper form is mailed to the individual. The data collected is valuable to a practice concerned with increasing its patient satisfaction scores.
There could be several reasons scores are affected. It may be something simple, such as a provider being on vacation or extended leave, so patients can’t get an appointment in what they consider an acceptable time frame. This could cause a low score for “access to care.” An individual who struggles with addiction to narcotics and leaves without having an opioid prescription refilled also may score the practice lower. Many of these situations can be alleviated with clear communication and by showing compassion or empathy. Simply listening and showing concern for what patients are going through will give them a different perspective of the situation.
Practices should not make assumptions about why patient satisfaction scores are low. Understanding the surveys and how they are completed will provide a road map for better understanding patients and opportunities for improvement.
Surveys
Know what is being asked on patient surveys, as various factors can affect how each person responds. For example, wait time for a retiree who has ample free time may be viewed differently by a busy working person who wants to be seen precisely at the appointment time. To understand this variation, parts of the survey will be broken out and participants of several age groups will be asked what the question means to them.
Identification
Patients also should understand who and what they are evaluating. Some patients, especially those with multiple health issues, may get multiple surveys for different offices or hospitals. The first section, labeled “The Provider,” establishes who is being assessed. The first question asked is, “Our records show that you visited the provider named below,” followed by the provider’s name in bold letters and the question, “Is this correct?” This helps verify whom the patient is evaluating and reduce the risk of false data.
Sometimes comments from patients don’t add up and require follow-up questions. For example, if an orthopedic office sees a comment such as, “My Pap results were delayed,” it is a pretty good indication that the patient is confused about which provider he or she is grading. If this happens, it is important to get those survey results removed from the reported data if you can verify the error.
Appointments and office contacts
The Appointments and Office Contact section measures access to care and communication with office staff. Patients are asked if the appointment was for an illness, injury or condition that needed immediate care. If they respond “yes,” they are asked if they received the immediate care they needed. This is a subjective question dependent on the individual and perhaps his or her age. Take the case of a small child who fell off a swing and went to an emergency department for evaluation. X-rays revealed a small, non-displaced fracture, and the patient was placed in an immobilizer and the parent was told to follow up with an orthopedic surgeon. The orthopedic office knew that the child could wait a few days to be treated, but the parent sees that the child is hurt and frightened and he or she does not know what to expect. The parent’s perception of when the child should be seen is much different. For the parent, this injury needs immediate care. Scheduling staff should be trained on accommodating for children and working them in as soon as feasible, even if it means overbooking the provider’s schedule.
Timeliness
The next questions concern the response time of communication with the staff, such as calling the office during business hours, after business hours and communicating test results. During hours that the office is open, the expectation is a same-day response. After hours, it is based on need and whether the patient feels he or she received an answer as soon as needed. The question regarding tests simply asks if someone communicated the results to the patient and does not require an answer about timeliness.
In the provider care section, the first question asks if the patient was seen within 15 minutes of his or her appointment time. The response may be “no” for various reasons. Patients, especially seniors, tend to arrive early to their appointment, and most offices advise patients to arrive 15 minutes early to update information. If they are in the waiting room at least 15 minutes before their scheduled time and don’t consider the actual appointment time, they will most certainly respond “no,” which will bring down scores. To avoid this, advise some established patients not to arrive early if it’s not necessary, or train your front office staff to thank patients for arriving early while gently reminding them of the actual time they are likely to be seen.
Communication
The survey then asks if the provider explained things in a way the patient understands. This is the provider’s responsibility, and some providers are much better at it than others. Providers should remember that while most patients are willing to learn and understand, they do not understand many medical terms. To help patients understand their conditions, providers can use pictures, models or show them their results and break it down to a level they understand. Providers then can simply ask if the patient has any questions. Listening to patients and repeating what they are saying will ensure that they know their concerns are heard. Providers should not leave the room until all concerns are addressed. They should also encourage patients to sign up for the patient portal, if available, to communicate questions or concerns after they leave the office. The portal is also important for the patient because the provider can send educational material, exercises and answers to questions through this avenue.
Providers are also rated on how well they know the patient’s medical history, medications and conditions. Patients should feel that the provider has a good understanding of their condition. They should have the patient record in front of them, and it should include tests and notes from other healthcare providers. Providers are also judged on the respect shown to the patient, caring and time spent. If the patient felt rushed, all the above are probably not going to rate well.
The last question in the provider section, and probably the most important is, “Would you recommend this provider?” This is a powerful inquiry and defines the way a patient feels. The likelihood of recommending is considered high on the scale when CMS reviews survey results. Since results are posted publicly, this question is crucial.
Clerks and receptionists are the focus of the next very small section in which patients are asked if these individuals were as helpful as expected and if they treated them with courtesy and respect. All of this can be positive with coaching and observation of staff. A friendly smile along with a greeting is expected. Taking the time to learn patients’ names and referring to them as “Mr.”, “Mrs.” or “Miss” along with their last name is respectful unless they express another preference. When they need help, front office staff should make sure to accommodate unless it is outside the scope of duties; then they should be helpful by finding someone who can help. Caring for patients and their needs should be a priority and done with a pleasant disposition. The way the staff speaks to patients, their body language and their attitude are noticed and usually influence the way patients rate the staff on the surveys.
Care access and throughput
“Access to Care and Moving through your visit” is a section for patients to describe their experience. Access addresses the ease of getting an appointment and getting someone on the phone, convenience of hours and courtesy of staff on the phone. Moving through the visit can depend on what the patients expect, but most times they just want to be informed of delays and what to expect from arrival to departure. Nurses or medical assistants (MAs) are rated on friendliness and courtesy as well as their concern for the patient. Providers are then judged on their friendliness, courtesy and concern for the medical problem of the patient and how well they explain the condition and treatment.
The wrap-up is concerned with how well the staff worked together during the visit and asks, “Would the patient recommend this practice?” The answers to all these questions are where the patient satisfaction scores come from. The higher the score, the better.
Improving scores
When looking for ways to increase the overall score of the practice, the medical staff is the best source for identifying reasons patients are unhappy or uncomfortable. Practices can have a brainstorming session to discuss comments and have the staff use each other’s ideas to come up with solutions.
One office raised its score by simply serving patients a beverage while they were in the waiting room or an exam room. When patients were taken back to the exam room, the MAs chatted with them, called them by name and offered them a bottle of water or soft drink. The patients were appreciative of the offer, whether they took it or not. They commented positively on their satisfaction surveys, and the scores around how they were treated by the staff and the amount of wait time improved.
Practices can use AIDET® as five steps to better communication. Created by Studer Group as a foundation for effective patient communication, it can be used by all healthcare staff:
- Acknowledge patient as a person and greet positively
- Introduce yourself and tell the patient what your role is
- Duration. Give a reasonable time expectation
- Explain. Make sure the patient is informed
- Thank the patient for being your partner
AIDET has been used in numerous healthcare organizations to help improve patient perception of care and service, and also reduce anxiety for both staff and patients. It increases better clinical outcomes by establishing better compliance. It builds patient loyalty and ensures that providers deliver complete and consistent measures of empathy, concern and appreciation for the patient. Communication is key to successful patient experience, and AIDET is a good reminder to focus on all the important parts.
Reviewing scores
There are many ways to make the patient experience as good as possible. But in some cases, the encounter falls below the patient’s expectation, and this should be addressed immediately. Each office should have policies to review their patient satisfaction scores at least monthly and reap useful information from them. Practices should run reports around the same time each month by the date of service and look at each section of the survey:
- Provider
- Nursing staff
- Reception staff
- Access to care
- Moving through the visit
- Personal issues
- Overall impression of the practice
- Comments
The results should be shared with staff and discussed at group meetings. By sorting by date, it is possible to explore why scores declined or comments were negative due to circumstances. For example, if access to care decreased and patients’ comments indicated that they couldn’t get an appointment within the time frame they felt was necessary, a practice can check if a provider was on vacation or sick. The scripting of the appointment schedulers can change when a provider is out of the office. This could change the expectation of the patient.
Comments, both good and bad, should be shared and examined. Practices can encourage the staff to tell patients their name several times, because it is likely that patients will mention them in their comments. Some staff may want to set their personal goal to be mentioned a certain number of times in the satisfaction surveys. Staff members who have made a positive impression on patients should be recognized. Negative comments should also be investigated to explore opportunities to improve. Some circumstances are beyond the control of the provider or staff, and that is worthy of discussion with the group. Everyone should understand that even when they work to the best of their abilities and go beyond what is expected of them, patients may not feel the same.
Outstanding patient satisfaction scores in a medical practice begin with an understanding of the patients. Practices should pay attention to the information supplied by the surveys returned by patients and what they indicate. Practices should review all sections of the survey, not just the ones that need improving. All aspects of the patient experience must be considered, and then practices can work on maintaining the score in areas that are getting high marks and improve on areas that score poorly.
Practices should take comments to heart and involve all stakeholders in creating methods to maintain and improve patient satisfaction. Practices might consider the diversity of the group that is served and realize that they should not be treated the same. Practices should respect the patient, communicate in a way they understand and give them the time they need.
Editor’s Note
This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.
Did you know?
The word most associated with negative reviews of hospitals on Yelp is “told,” according to a Penn Medicine study authored by Anish K. Agarwal, Arthur P. Pelullo and Raina M. Merchant, recently published in the Journal of General Internal Medicine. When it comes to positive reviews, the words “great” and “friendly” show up with high frequency.
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