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BackgroundThe Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts.Topics covered.Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience?Key themesProviders and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.

Objective: To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores. Data Sources and Setting: We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in‐depth interviews with practice leaders and staff; and 9551 modified CG‐CAHPS patient experience surveys augmented by open‐ended narrative elicitation questions. Study Design: We conducted a cluster quasi‐experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free‐form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control‐versus‐intervention site differences in learning, behavior, and patient experience scores. Data Collection: Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre‐launch through 9 months post‐launch. We used control‐versus‐intervention and difference‐in‐difference analyses for survey data and thematic analysis for interview data. Principal Findings: Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%. Conclusions: Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non‐clinical interaction. [ABSTRACT FROM AUTHOR]

Policy PointsPatients' creative ideas may inform learning and innovation that improve patient‐centered care.Routinely collected patient experience surveys provide an opportunity to invite patients to share their creative ideas for improvement. We develop and assess a methodological strategy that validates question wording designed to elicit creative ideas from patients.Health care organizations should consider how to report and use these data in health care delivery and quality improvement, and policymakers should consider promoting the use of narrative feedback to better understand and respond to patients' experiences. Context: Learning health systems (LHSs) have been promoted for a decade to achieve high‐quality, patient‐centered health care. Innovation driven by knowledge generated through day‐to‐day health care delivery, including patient insights, is critical to LHSs. However, the pace of translating patient insights into innovation is slow and effectiveness inadequate. This study aims to evaluate a method for systematically eliciting patients' creative ideas, examine the value of such ideas as a source of insight, and examine patients' creative ideas regarding how their experiences could be improved within the context of their own health systems. Methods: The first stage of the study developed a survey and tested strategies for elicitation of patients' creative ideas with 600 patients from New York State. The second stage deployed the survey with the most generative open‐ended question sequence within a health care system and involved analysis of 1,892 patients' responses, including 2,948 creative ideas. Findings: Actionable, creative feedback was fostered by incorporating a request for transformative feedback into a sequence of narrative elicitation questions. Patients generate more actionable and creative ideas when explicitly invited to share such ideas, especially patients with negative health care experiences, those from minority racial/ethnic backgrounds, and those with chronic illness. The most frequently elicited creative ideas focused on solving challenges, proposing interventions, amplifying exceptional practices, and conveying hopes for the future. Conclusions: A valid and reliable method for eliciting creative ideas from patients can be deployed as part of routine patient experience surveys that include closed‐ended survey items and open‐ended narrative items in which patients share their experiences in their own words. The elicited creative ideas are promising for patient engagement and innovation efforts. This study highlights the benefits of engaging patients for quality improvement, offers a rigorously tested method for cultivating innovation using patient‐generated knowledge, and outlines how creative ideas can enable organizational learning and innovation. [ABSTRACT FROM AUTHOR]

Background: Enthusiasm has grown about using patients' narratives—stories about care experiences in patients' own words—to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published. Purpose: We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores. Approach: We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources. Results: Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge (p <.01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient–provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff. Conclusion: Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge. Practice Implications: Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study was to identify issues, obstacles, and priorities related to implementing and using child health care quality measures from the perspectives of 4 groups: 1) funders of quality-measurement development and implementation; 2) developers of quality measures; 3) users of quality measures (including Medicaid and the State Children&apos;s Health Insurance Program, employer coalitions, and consumer groups); and 4) health plans and providers (in their role as both subjects and users of quality measures). Methods. A series of semistructured interviews was conducted with ~40 opinion leaders drawn from these 4 groups. The interviews were conducted by telephone between September and December of 2001. Major topic areas covered in the interviews were similar across the groups. Topic areas included 1) strategic vision and/or objectives for funding, developing, or using quality measures for children&apos;s health care; 2) a brief summary of the specific quality measures funded, developed, or used; 3) issues and challenges facing funders and developers of measures; 4) major successes achieved; 5) obstacles to implementation and use of measures; and 6) priority needs for future funding. Results. Leaders from all 4 groups acknowledge the importance of developing a robust set of quality measures that can serve multiple objectives and multiple audiences. Standardization of measures is viewed as a critical feature related to all objectives. An assessment of specific quality measures funded, developed, or used by strategic objective shows a high correlation between the uses intended by funders and developers and the actual applications of the various users. The most commonly cited measures across all groups are the Consumer Assessment of Health Plans Survey and Health Plan Employer Data and Information Set, followed by the Child and Adolescent Health Measurement Initiative and special topic studies to support quality-improvement applications (eg, asthma, diabetes, etc). The major issues and challenges cited in common among funders and developers are 1) the lack of trained capacity in the field to conduct needed research and development, and 2) the difficulty in generating sustained interest and support among funders because of the complexity of quality-measurement issues, competing funding priorities in the face of limited funds available to allocate, and the lack of clear and compelling evidence that quality measurement and improvement actually result in better outcomes for children. The 3 most common successes cited across all 4 groups are 1) the growing consensus and collaboration among diverse stakeholder groups involved in measurement development and implementation; 2) the increasing collection and use of specific measures; and 3) early documentation of tangible results in terms of improved quality of care. Specific measurement tools cited as successes by funders and developers include the Medicaid Health Plan Employer Data and Information Set, Consumer Assessment of Health Plans Survey, the Child and Adolescent Health Measurement Initiative, and Rand QA Tools. The most important obstacle reported across all groups is the lack of a strong and compelling "business case" that clearly demonstrates the benefits of quality measurement relative to the costs of implementation. Strongly related to this barrier is the cost of implementing and using measures without a sustainable source of financing as well as the absence of strong public awareness and political support for children&apos;s health care quality measurement. Another major barrier cited is the lack of coordination among funders, which prevents the field from developing a unified approach to addressing the numerous technical, political, and administrative issues also cited at length by the leaders interviewed. The 5 top needs for future funding identified across all 4 groups follow directly from the major obstacles that they reported: 1) develop the business case for children&apos;s health care quality measurement and improvement based on rigorous cost-benefit analysis and documentation of quantifiable successes; 2) develop new measures to fill the gaps in critical areas (including adolescent health care, behavioral health, and chronic conditions) that can be applied at the hospital and ambulatory care provider levels; 3) invest in building needed research capacity, a trained pool of users of quality measures, and the capacity among providers to understand and use quality-improvement methods and tools; 4) invest in developing an information infrastructure that will support the efficient collection and use of measures for multiple purposes, including clinical practice, quality measurement, and quality improvement; and 5) develop increased public awareness and support for quality measurement based on improved strategies for communicating with consumers, purchasers, providers, and policy makers. Conclusions. Several implications are suggested by these perspectives for the future direction of quality measurement in children&apos;s health care. First, to meet the funding needs identified, many funders must improve coordination to reduce the noise and fragmentation generated by numerous competing or redundant activities. Improved coordination among funders will help assure maximum impact and the efficient use of scarce resources. Second, the importance attached to standardization of measures by both users and developers may conflict at times with the need for innovation and flexibility. Child health quality leaders will need to manage this tension between standardization and innovation to maintain an appropriate balance between the benefits of both. Finally, many of the obstacles identified are not unique to children&apos;s health care. Child health quality leaders will need to determine to what extent their efforts to overcome these obstacles can be successfully undertaken independently as opposed to in concert with groups concerned about other populations and sectors in the health care system. Pediatrics 2004;113:217-227; child health care quality, quality measurement, quality improvement., The growing evidence of problems with the quality of health care in the United States has focused increased attention on the relative lack of measures designed specifically to assess the [...]

A national policy is needed to coordinate the various state and regional groups providing information on the quality of health care. Consumers, physicians, employers and health care plans all need information and the quality of health care. Although these information systems would be formed at the local level, they would use national standards to determine the quality of health care. Existing systems include the Minnesota Health Data Institute, the California Cooperative Health Care Reporting Initiative and the Cleveland Health Quality Choice program., Concerted national action is needed to meet the growing demand for health care quality information among all health care stakeholders. We propose a coordinated national network of independent, public-private quality measurement alliances established through strong purchaser and consumer leadership at the state, regional, or local levels. These independent alliances could assume a variety of organizational forms, but all would undertake specific quality measurement and consumer information projects to meet local health care market needs by drawing on various combinations of the emerging national standardized quality measures. Local implementation of quality measures based on national standards will facilitate cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Successful models of such alliances already exist that demonstrate the feasibility of this national strategy, but concerted national leadership and federal matching funding will be needed to meet the scope of implementation required in markets across the country. JAMA. 1998;279:1254-1258

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients' expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients' comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to "manage" providers' reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness. [ABSTRACT FROM AUTHOR]

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants (N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers' stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts. [ABSTRACT FROM AUTHOR]

Outlines principles to improve the effectiveness and impact of public reporting of health care quality. Convincing consumers that quality problems are real and consequential; Standardization of quality reporting; Dissemination of quality information to consumers; Health care providers' creation of information and organizational infrastructure to achieve them.

For two decades, various initiatives have encouraged Americans to consider quality when choosing clinicians, both to enhance informed choice and to reduce disparities in access to high-quality providers. The literature portrays these efforts as largely ineffective. But this depiction overlooks two factors: the dramatic expansion since 2010 in the availability of patients' narratives about care and the growth of information seeking among consumers. Using surveys fielded in 2010, 2014, and 2015, we assessed the impact of these changes on consumers' awareness of quality information and sociodemographic differences. Public exposure to any quality information doubled between 2010 and 2015, while exposure to patient narratives and experience surveys tripled. Reflecting a greater propensity to seek quality metrics, minority consumers remained better informed than whites over time, albeit with differences across subgroups in the types of information encountered. An education-related gradient in quality awareness also emerged over the past decade. Public policy should respond to emerging trends in information exposure, establish standards for rigorous elicitation of narratives, and assist consumers' learning from a combination of narratives and quantified metrics on clinician quality. [ABSTRACT FROM AUTHOR]

Efforts to engage consumers in the use of public reports on health care provider performance have met with limited success. Fostering greater engagement will require new approaches that provide consumers with relevant content at the time and in the context they need to make a decision of consequence. To this end, we identify three key factors influencing consumer engagement and show how they manifest in different ways and combinations for four particular choice contexts that appear to offer realistic opportunities for engagement. We analyze how these engagement factors play out differently in each choice context and suggest specific strategies that sponsors of public reports can use in each context. Cross-cutting lessons for report sponsors and policy makers include new media strategies such as a commitment to adaptive web-based reporting, new metrics with richer emotional content, and the use of navigators or advocates to assist consumers with interpreting reports. [ABSTRACT FROM AUTHOR]

Health care consumers often make choices that are imperfectly informed and inconsistent with their expressed preferences. Past research suggests that these shortcomings become more pronounced as choices become more complex, through either additional options or more performance metrics. But it is unclear why this is true: Consumer choice remains a “black box” that research has scarcely illuminated. In this article, we identify four pathways through which complexity may impair consumer choice. We examine these pathways using data from an experiment in which consumers (hypothetically) selected a primary care physician. Some of the loss of decision quality accompanying more complex choice sets can be explained by consumers’ skills and decision-making style, but even after accounting for these factors, complexity undermines the quality of decision making in ways that cannot be fully explained. We conclude by discussing implications for report designers, sponsors, and policy makers aspiring to promote consumer empowerment and health care quality. [ABSTRACT FROM AUTHOR]

Patients value the interpersonal aspects of their health care experiences,. However, faced with multiple resource demands, primary care practices may question the value of collecting and acting upon survey data that measure patients' experiences of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys and quality improvement tools supports the systematic collection of data on patient experience. Collecting and reporting CAHPS data can improve patients' experiences, along with producing tangible benefits to primary care practices and the health care system. We also argue that the use of patient experience information can be an important strategy for transforming practices as well as to drive overall system transformation. [ABSTRACT FROM AUTHOR]

Objective: Advances in health care require that individuals participate knowledgeably and actively in their health care to realize its full benefit. Implications of these changes for the behavior of individuals and for the practice of patient education are described. Methods: An “engagement behavior framework” (EBF) was compiled from literature reviews and key informant interviews. To assess the focus of research and interventions on the identified engagement behaviors, the EBF was used to code scientific sessions in professional conferences relevant to patient education in the US in 2006–2007. Results: Many specific behaviors constitute engagement. Professional conferences on patient education show only modest attention to the full range of relevant behaviors. Conclusion: People must make informed choices about insurance and clinicians, coordinate communications among providers and manage complex treatments on their own. Not doing so risks preventable illness, suboptimal outcomes and wasted resources. Practice Implications: Increased responsibilities of individuals, sick and well, to find and actively participate in high quality health care provides an opportunity for patient education researchers and clinicians to improve health outcomes by developing innovative strategies to support all individuals to effectively participate in their care to the extent possible. [Copyright &y& Elsevier]

Objectives: To understand the views of prominent organizations in the field of healthcare quality on the topic of reporting roll-up measures that combine indicators of multiple, often disparate, dimensions of care to consumers., Study Design: This study used a semi-structured, qualitative interview design., Methods: We conducted 30- to 60-minute semi-structured telephone interviews with representatives of 10 organizations that sponsor public healthcare quality reports and 3 national alliances representing multiple stakeholder groups. We conducted a thematic analysis of interview transcriptions to identify common issues and concerns related to reporting roll-up measures., Results: Among sponsors reporting roll-up measures, current practices for calculating and reporting these measures are diverse. The main perceived benefit of reporting roll-up measures is that they simplify large amounts of complex information for consumers. The main concern is the potential for consumers to misunderstand the measures and what associated roll-up scores communicate about provider performance. Report sponsors and national alliances feel that more guidance and research on the methods for producing and reporting scores for roll-up measures are needed., Conclusions: The results of the interviews elucidate the need for research focused on construction and reporting of roll-up measures. Studies are needed to determine if roll-up measures are indeed perceived by consumers as being less complex and easier to understand.