Advancing Methods of Implementing and Evaluating Patient Experience Improvement Using CAHPS® Surveys: Summary of Presentations

Lisa Franchetti, MA, CPHQ, Customer Experience Manager, Neighborhood Health Plan of Rhode Island

Topic: Improving enrollee experience with a health plan’s customer service

Neighborhood Health Plan (Neighborhood) serves more than 199,000 members, over 50% of whom are adults eligible for Medicaid or dually eligible for Medicare and Medicaid, and uses the CAHPS Medicaid Adult Survey for accreditation and other purposes. Neighborhood identified a need to focus on improving customer service by oversampling plan members, analyzing trends in CAHPS composite measures, and using a key driver analysis. To learn more about the issues affecting the CAHPS customer service scores, the plan began collecting patient survey data off-cycle and mining their member call logs for additional insights. They then implemented over a dozen interventions to address the identified problems. These interventions included creating additional training for new hires, monitoring call center conversations, and enhancing their processes for first call resolution. As a result of these interventions, Neighborhood has achieved and been able to maintain improvements in its CAHPS scores on the “courtesy and respect” and “customer service” composite measures and the overall health plan rating.

Deborah Wafer, MSPD, Director, Ambulatory Operations, UCLA Health, and Dr. Samuel A. Skootsky, MD, Chief Medical Officer, UCLA Faculty Practice Group and Medical Group, UCLA Health

Topic: Improving patient experience with communication in ambulatory care settings

UCLA administers the CAHPS Clinician & Group Survey (CG-CAHPS) to its adult and child primary and specialty care patients. CAHPS data are used to understand patients’ experiences with provider communication and assess the need for physician training and coaching. CAHPS scores are also a key part of their initiative to train ambulatory clinical directors, office managers, and other staff to focus on every aspect of the patient care experience and track performance over time. Their efforts embed the CG-CAHPS metrics into targeted behaviors included in their training and as part of their management performance tracking.

Stephanie Fishkin, PhD, Principal Consultant, Center for Healthcare Analytics, Kaiser Permanente

Topic: Improving patient experience with communication about medications in hospitals

Kaiser Permanente administers and tracks the CAHPS Hospital Survey (HCAHPS) for 40 hospitals. They conduct census sampling to focus on improvement needs at the unit level. Based on a trend analysis, Kaiser Permanente identified the CAHPS “medication communication” composite measure as an area for improvement. Based on prior efforts to achieve and sustain improvements, Kaiser Permanente conducted a gap analysis, created an interdisciplinary team, sought insights from external and internal sources, conducted a pilot study of a workflow to improve specific aspects of medication communication, and then created a standardized playbook that lays out responsibilities, implementation timelines, and implementation resources. They also took steps to remove barriers by giving stakeholders a voice in the process and seeking buy-in at the local, cross-regional, and cross-entity levels. As a result of these efforts, Kaiser Permanente’s scores for the HCAHPS medication communication composite measure have improved since 2015.

Kerri Cavanaugh, MD, MHS, Associate Professor of Medicine, Vanderbilt University Medical Center

Topic: Improving patient experience with care for end-stage kidney disease

Results from the CAHPS In-Center Hemodialysis Survey (ICH CAHPS) can be used to create unit-level reports of performance and identify key domains for improvement, with specific attention paid to what components are driving high or low scores. Vanderbilt University Medical Center’s dialysis facilities implemented a variety of strategies to make patients and families aware of the survey, its results, and the importance of participating. For example, in letters sent to patients, they present overall unit-level scores, acknowledge areas of success, and share plans and strategies for improvement at the facility, physician, and staff level. The facilities also collect additional data (such as patient grievances and internal patient experience surveys), set goals by domain, and discuss and refine practice changes with clinicians and staff.

Ingrid Nembhard, PhD, Associate Professor of Health Care Management, The Wharton School at the University of Pennsylvania

Topic: Use of patient narratives for quality improvement by medical groups

NewYork-Presbyterian administers a version of the CAHPS Clinician & Group Survey that includes the CAHPS Narrative Elicitation Protocol, a set of five open-ended questions that obtain a comprehensive story of a patient’s experience with care in an ambulatory setting. The study is designed to assess the feasibility, value, and use of the CAHPS narrative items in ambulatory practices using a two-phase quasi-experimental study with nine sites. The study highlights the importance of using experimental study designs and developing interventions collaboratively with organizational members. With input from clinicians, administrators, and staff at NewYork-Presbyterian, the research team worked with a design firm to develop an innovative online feedback tool that reports patients’ comments to practices. Using a mixed-methods study approach, including qualitative and statistical analyses as well as surveys and interviews of clinic leaders and staff, the team has found that the CAHPS narrative items provide new information that supplements the survey scores and offers actionable insights.

Mark Friedberg, MD, Senior Vice President of Performance Measurement and Improvement, Blue Cross Blue Shield of Massachusetts

Topic: Improving performance on the CAHPS Health Plan Survey and the CAHPS Clinician & Group Survey

Blue Cross Blue Shield of Massachusetts reviews and uses data from both the CAHPS Health Plan Survey and the Clinician & Group Survey. Methods used to improve CAHPS scores have included incentives for improvement, network curation, steerage to high performers, and direct-to-member approaches (such as improving member services). When interpreting movements in CAHPS scores over time, it is important for health plans to distinguish significant changes (“signal”) from random changes (“noise”).

Denise D. Quigley, PhD, Health Policy Researcher at RAND and Professor of Policy Analysis at the Pardee RAND Graduate School, and Dr. Efrain Talamantes, Chief Operating Officer, AltaMed Health Services

Topic: Improving physician communication through shadow coaching and financial incentives

AltaMed Health Services administers the CAHPS Clinician & Group Visit Survey 2.0 for adult and child patients. To improve its CAHPS scores, AltaMed developed a shadow coaching program that identifies medium-performing providers based on the CAHPS overall provider rating. Those providers are invited to participate in peer coaching with a high-performing coach and are then shadowed for a half to full day with immediate verbal feedback and a written report of recommendations. Every six months, all providers, coached or not, receive a pay-for-performance incentive payment based on their CAHPS scores. RAND’s ongoing study evaluates the influence of the combination of the shadow coaching program and the incentives on providers’ CAHPS scores. The study was designed to assess the initial coaching effort and also, with a wait-list control design, evaluate the effects of re-coaching. The evaluation team modeled the effects of AltaMed’s interventions using CAHPS scores over a 7-year timeframe; the researchers also analyzed provider perceptions assessed by a survey and interviews and the content of the coaching reports. The results showed that coaching improved providers’ overall provider rating and CAHPS communication scores, but these improvements faded over time.

Jim Schaefer, MPH, Director of Surveys, Office of Reporting, Analytics, Performance, Improvement & Deployment, and Jennifer Purdy, Executive Director, Veterans Patient Experience Program, Department of Veterans Affairs (VA)

Topic: Improving patient experience with ambulatory and hospital care

The VA administers its CAHPS-based Survey of Healthcare Experience of Patients (SHEP) to patients receiving care from patient-centered medical homes and specialty care providers. It also uses the CAHPS Hospital Survey. They used a driver analysis to identify the direct and indirect drivers of overall ratings and estimate the impact of changes in different areas. Through a journey mapping exercise, they also developed a stronger understanding of the patients’ experiences and potential solutions. Based on what they learned, they then rolled out solutions using a patient experience toolkit implemented across the VA clinic sites. The four-year effort included: 1) building the pilot toolkit, 2) using the toolkit at sites to, among other things, develop leadership and employee engagement, 3) assessing site needs and identifying key outcomes to target and improve, and 4) building the program through standardization across sites and developing accountability for outcomes. This process of developing and implementing the toolkit led to an improvement in the VA Compare star scores compared to 2 years prior, as well as better HCAHPS scores than other hospitals on communication with nurses, care transitions, overall rating of the hospital, and overall star rating.

Natalie McNeal, MBA, MHA, Executive Director, Wellstar Community Hospice

Topic: Improving patient experience with hospice care

Wellstar administers the CAHPS Hospice Survey in accordance with CMS guidelines. They used an A-3 Lean methodology with PDSA cycles, root cause analysis, and structured performance reports to make and track improvements in CAHPS scores. They identified the need to improve scores on the “listening carefully regarding care problems” composite measure because their system scored below the benchmarks and their system goals. While the work is still in progress, they saw an increase in scores after implementing changes and training. They also identified some barriers to making improvements, including the lag time between when the CAHPS survey is administered and the last date of care and the emotional nature of bereavement for respondents. Their efforts highlight the need for experts to guide a QI team through the Lean process, assist in setting attainable goals, and support the practical steps of the QI process. Recommendations based on this work include focusing on improvements in the implementation process rather than failures and examining possible causal factors in addition to root causes.