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Research on Improving Patient Experience

Many researchers study the feasibility and value of using CAHPS surveys to support efforts to improve patient experience in various healthcare settings. This page summarizes current and recent research funded under AHRQ’s CAHPS grants related to:

  • Improving patient experience with ambulatory care.
  • Improving patient experience with hospital care.

Review all citations for quality improvement in the CAHPS bibliography.

Improving Patient Experience with Ambulatory Care

Aim/Purpose: This project has two goals. The first goal is to learn how ambulatory care practices can use measures of patient engagement and shared decision-making to support patients with chronic disease management. The second is to learn how to design targeted improvement coaching and educational programs to efficiently enhance doctor-patient communication and patient engagement in chronic disease management.    

Key Questions:

  • How effective is a quality improvement intervention in improving patient engagement and shared decision making for patients managing chronic disease?
  • How do vulnerable patients and those from different racial and ethnic backgrounds view physician engagement efforts? What are their ideas for practical things their clinicians can do to promote patient engagement?
  • What are physicians’ perceptions of potential facilitators and barriers to patient engagement?

Research Team: Yale

Aim/Purpose: Communication between providers and patients is a critical aspect of the patient experience. Most healthcare settings provide interpreter services and translate information for their non-English preferring patients, but language disparities in care still exist. The research team partnered with two Federally Qualified Health Centers (FQHCs) to examine provider-patient language concordance (i.e., when the provider is fluent in the patient’s preferred language) and the use of interpreter services with the aim of improving the ambulatory care experiences of Spanish-preferring patients. 

Key Questions:

  • What are the perspectives of Spanish-preferring patients about their care when provided by a Spanish-qualified provider versus using an interpreter? What can be improved?
  • What are the perspectives of providers on their strategies for communicating with Spanish-preferring patients for those who rely on an interpreter? What can be improved?
  • Does patient experience differ by patient-provider language concordance, i.e., comparing experiences of (a) Spanish-preferring primary care patients who see a provider who is not qualified in Spanish so they need/use a formal or informal interpreter to communicate and (b) Spanish-preferring patients who see a Spanish-qualified provider? What can be improved?
  • Does the implementation of additional language supports/strategies for Spanish-preferring patients improve their experience with care?

Published Articles:

  • Quigley, D.D., Qureshi, N., Predmore, Z., Diaz, Y., Hays, R.D. Is Primary Care Patient Experience Associated with Provider-Patient Language Concordance and Use of Interpreters for Spanish-preferring Patients: A Systematic Literature Review. Journal of Racial and Ethnic Health Disparities. 2024;0(0). [In press]. doi: 10.1007/s40615-024-01951-z.

Research Team: RAND

Aim/Purpose: Patient narratives, or feedback from patients in their own words, can complement closed-ended survey questions by revealing reasons for survey scores, raising topics not otherwise included in standardized survey questions, and providing specific insights for improvement. However, evidence about the relative effectiveness of different protocols for eliciting patient narratives has been lacking. Moreover, how healthcare professionals absorb and respond to the patient narratives that they see is unknown, yet critical given the importance of worker well-being for delivering good care.

Key Questions:

  • What is the added value of the CAHPS Clinician & Group Narrative Item Set compared to conventional open-ended questions?
  • What is the perceived usefulness of patient narrative feedback in primary care settings?
  • Is there a link between staff seeing patient narratives and feeling burnout?  If so, why?

Published Article: 

Grob, Rachel PhD; Lee, Yuna S.H. MPH, PhD; Shaller, Dale MPA; Warne, Emily BS; Matta, Sasmira MHS; Schlesinger, Mark PhD; Nembhard, Ingrid M. MS, PhD. “Nothing Is More Powerful than Words:” How Patient Experience Narratives Enable Improvement. Quality Management in Health Care 33(3):p 149-159, July/September 2024. | DOI: 10.1097/QMH.0000000000000477

Research Team: Yale

Aim/Purpose: 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 been lacking. This stream of work assessed whether primary care clinics that frequently share patients’ narratives with their staff to inform their quality improvement efforts have higher patient experience survey scores. It also investigated the properties of the ideas shared by patients that facilitate improvement (e.g., idea creativity and actionability) and the value of explicitly inviting patients to share their creative ideas for improvement.

Key Findings:

  • Patient narratives often contain creative and actionable ideas for patient experience improvement, even more so when narrative elicitation protocols include an explicit invitation to patients to share their creative ideas and mentions the potential system impact. 
  • 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
  • Frequency of sharing useful narratives with staff is associated with patient experience scores for multiple measures, conditional on staff confidence in own knowledge of patients and practice.
  • For operational measures of patient experience (timely access to care and care coordination), increased sharing of narratives with staff correlates with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure.
  • For relational measures of patient experience (e.g., patient-provider communication and office staff courtesy and helpfulness), increased sharing correlates with higher scores for less confident staff and lower scores for more confident staff.

Published Articles:

  • Lee, Y.S.H., Grob, R., Nembhard, I.M., Shaller, D. and Schlesinger, M. (2024). Leveraging Patients’ Creative Ideas for Innovation in Health Care. The Milbank Quarterly 102(1), pp. 233-269.
  • Nembhard IM, Matta S, Shaller D, Lee YSH, Grob R, Schlesinger M. Learning from Patients: The Impact of Using Patient Narratives on Patient Experience Scores. Health Care Management Review. January-March 2024. 49(1):2-13. DOI: 10.1097/HMR. 000000000000386.

Research Team: Yale

Aim/Purpose: Patient narratives, or feedback from patients collected through structured open-ended survey questions, can provide useful insights for supporting efforts to improve quality of care and patient experience. However, collection of patient narratives is insufficient to assure their use because medical practice staff and clinicians often face challenges in learning from and using patient narratives to induce change. The research team collaborated with New York-Presbyterian Hospital 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.

Key Findings

  • Reporting interventions designed to facilitate interpretation of patients’ narrative feedback can motivate staff learning and behavior changes and lead to improvements in aspects of patient experience targeted for improvement.
  • Learning and behavior changes motivated by enhanced narrative feedback reporting appear to be greater among non-clinical staff.
  • Promoting awareness and use of narratives among clinicians may require different strategies than those employed for non-clinical staff.

Published Articles:

  • Shaller D, Nembhard IM, Matta S, Grob R, Lee YSH, Warne E, Evans R, Dicello D, Colon M, Polanco A, Schlesinger M. Assessing an Innovative Method to Promote Learning from Patient Narratives: Findings from a Field Experiment in Ambulatory Care. Health Serv Res 2023;1-14. doi: 10.1111/1475-6773.14245

Related Resources: 

Research Team: Yale

Aim/Purpose:  The research team evaluated the use of shadow coaching and a second follow-up re-coaching session under a pay-for-performance incentive tied to CAHPS Clinician & Group Survey measures within a large urban Federally Qualified Health Center in California. The team also assessed whether the effects of shadow coaching were consistent across different patient groups.

Key Findings:

  • Shadow coaching improved providers’ overall performance and communication with patients immediately after being coached.
  • Half of the recommendations provided by coaches to the coached providers encouraged consistency of existing behaviors and half encouraged new behaviors.
  • Re-coaching improved patient experience more than the initial coaching, suggesting reactivation of knowledge from the initial coaching.
  • The effects of shadow coaching and re-coaching eroded over time as providers gradually slipped back into their previous habits of interacting with patients, suggesting that coaching should occur every 6 to 12 months to maintain behaviors and scores.
  • Coaching improved care experiences for English-preferring patients but the evidence does not indicate that coaching improved patient experience for Spanish-preferring patients.

Published Articles:

  • Quigley, D.D., Predmore, Z., Martino, S., Qureshi, N., Hays, R.D.2023. Patient Comments on the CAHPS Clinician and Group Survey Reflect Improvements in Provider Behaviors from Shadow Coaching. Journal of Healthcare Management 68(4): 251-267. https://doi.org/10.1097/JHM-D-22-00140. 
  • Quigley DD, Elliott MN, Slaughter ME, Talamantes E, Hays RD. Shadow Coaching Improves Patient Experience for English-Preferring Patients but not for Spanish-Preferring Patients. Journal of General Internal Medicine 2023. https://doi.org/10.1007/s11606-023-08045-2.
  • Quigley DD, Elliott MN, Slaughter ME, Hays RD. Follow-up Shadow Coaching Improves Primary Care Provider-Patient Interactions and Maintains Improvements When Conducted Regularly: A spline model analysis. Journal of General Internal Medicine. 2023. 38: 221–227. https://doi.org/10.1007/s11606-022-07881-y.
  • Quigley DD, Qureshi N, Palimaru A, Pham C, Hays RD. Content and Actionability of Recommendations to Providers After Shadow Coaching. Quality Management in Health Care 2022. doi: 10.1097/QMH.0000000000000354. Epub ahead of print. PMID: 35170583.
  •  Quigley DD, Elliott MN, Slaughter ME, Burkhart Q, Chen A, Talamantes E, Hays RD. Shadow Coaching Improves Patient Experience with Care, But Gains Erode Later. Medical Care 2021. 59(11):950-960. doi: 10.1097/MLR.0000000000001629.PMCID: PMC8516705.
  • Quigley DD, Qureshi N, Slaughter ME, Kim S, Talamantes E, Hays RD. Provider and Coach Perspectives on Implementing Shadow Coaching to Improve Provider-Patient Interactions. Journal of Evaluation of Clinical Practice 2021. 27: 1381-1389. doi.org/10.1111/jep.13575. PMID: 34014026.

Aim/Purpose: Burnout negatively impacts patient care experiences and safety. Using data from a cross-sectional survey of primary care providers in a large Federally Qualified Health Center, the research team examined the associations of provider burnout with their perspectives on patient experience measurement, quality improvement (QI), and clinic culture, including the adequacy of staffing.

Key Findings:

  • Providers who had a higher QI orientation and engagement and perceived having more clinic leadership support and commitment to patient experience measurement reported not being burned out (compared to those reporting burnout).
  • More facilitative clinic leadership, more information and sensemaking throughout the clinic, and fewer patient care issues were also associated with not being burned out.

Published Articles: 

  • Quigley, D. D., Slaughter, M. E., Qureshi, N., & Hays, R. D. (2024 epub). Associations of primary care provider burnout with quality improvement, patient experience measurement, clinical culture and job satisfaction. JGIM. 
  • Quigley, D. D., Slaughter, M. E., Qureshi, N., Gidengil, C., & Hays, R. D. (2023). Associations of pediatric nurse burnout with involvement in quality improvement. Journal of Pediatric Nursing 70, e9-e16. doi: 10.1016/j.pedn.2022.11.001.

Research Team: RAND

Aim/Purpose: The purpose of this study was to learn from a stratified national sample of 105 practices engaged in PCMH transformation about how leaders and staff in primary care practices used CAHPS Clinician & Group Survey data, including the CAHPS PCMH items, during the process of becoming medical homes.

Key Findings:

  • Practice leaders used CAHPS survey results to discuss best practices, share data with advisory councils, and improve provider performance.
  • Practices undergoing PMCH transformation nationwide most commonly made care delivery changes that improved access and continuity of care.
  • Leaders highlighted a survey’s ability to track performance against other practices as an important tool for continued improvement. Such benchmarking is only possible with data that is systematically collected across a large number of practices.
  • Many changes made during PCMH transformation are improvements that can be measured and monitored by CAHPS patient experience items. Changes that are not captured in CAHPS surveys include care management to support medical and chronic conditions and chronic condition health education.

Published Articles:

  • Quigley DD, Qureshi N, Hays RD. Reasons Primary Care Practices Chose Patient Experience Surveys during Patient-Centered Medical Home Transformation. Journal of Ambulatory Care Management 2022. 46(1):34-44 doi: 10.1097/JAC.0000000000000442
  • Quigley DD, Qureshi N, AlMasarweh L, Pham C, Hays RD. Using CAHPS® Patient Experience Data for Patient-Centered Medical Home Transformation. The American Journal of Managed Care 2021. 27(9):e322-e329. e322-e329. doi:10.37765/ajmc.2021.88745. PMID: 34533915.
  • Quigley DD, Slaughter ME, Qureshi N, Elliot MN, Hays RD. Practices and Changes Associated with Patient-Centered Medical Home Transformation. The American Journal of Managed Care 2021. 27(9):386-393. doi: 10.37765/ajmc.2021.88740. PMID: 34533908.
  • Quigley DD, Qureshi N. PCMH Transformation Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Data. Medical Home News 2021. 12(24): 1,5-6.
  • Quigley DD, Qureshi N, AlMasarweh L, Hays RD. Practice Leaders Report Targeting Several Types of Changes in Care Experienced by Patients During Patient-Centered Medical Home Transformation. Journal of Patient Experience 2020. 7(6):1509-1518. doi: 10.1177/2374373520934231. PMCID: PMC7786645.
  • Xenakis L, Quigley DD, Qureshi N, AlMasarweh L, Pham C, Hays RD. 2020. Some Aspects of Patient Experience Assessed by Practices Undergoing Patient-Centered Medical Home Transformation are Measured by CAHPS, Others are Not. Quality Management in Healthcare. 2020. 29(4):179-187. doi: 10.1097/QMH.0000000000000263. PMID: 32991534.
  • Qureshi N, Quigley DD, Hays RD. Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home. Journal of General Internal Medicine 2020. 35(12):3501-3509. doi: 10.1007/s11606-020-06052-1. PMCID: PMC7728968.
  • Quigley DD, Predmore ZS, Hays RH. Tools to Gauge Progress during Patient-Centered Medical Home Transformation. The American Journal of Accountable Care 2017. 5(4):e8-e18.
  • Setodji, C.M., Quigley, D.D., Elliott, M.N., Burkhart, Q, Hochman M., Chen A., Hays, R.H. 2017. Patient Experiences with Care Differ with Chronic Care Management in a Federally Qualified Community Health Center. Population Health Management 20(6):442-448. doi:10.1089/pop.2017.0003. PMID: 28387598. 
  • Quigley, D.D., Palimaru A.I., Chen A.Y., & Hays R.D. 2017. Implementation of Practice Transformation: Patient Experience According to Practice Leaders. Quality Management in Health Care 26(3):140-151. PMCID: 6724179. 
  • Quigley, D.D., Predmore, Z.S., Chen, A., Hays, R.H. 2017. Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients. Quality Management in Health Care 26(1):7-14. PMID: 28030459. 
  • Quigley, D.D., Mendel, P., Predmore, Z.S., Chen, A., Hays, R.H. 2015. Use of CAHPS Patient Survey Data as Part of a Patient-Centered Medical Home Quality Improvement Initiative: Initial Evaluation. Journal of Healthcare Leadership 7:41-54. PMCID: PMC5740994.

Research Team: RAND

Aim/Purpose: The research team evaluated the impact of a nurse care coordinator program on patients' health and care experience, as well as staff interactions and work experiences, in 12 Connecticut community health centers. The CAHPS Clinician & Group Survey with the Patient-Centered Medical Home items and other supplemental items that ask about coordination of care were used to assess changes in patients' experiences of care.

Key Findings:

  • Adding care coordination to nurses' roles had some positive effects, including a small improvement in patient experience for program enrollees and a significant increase in office visits for enrolled patients.
  • Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.
  • The use of brainstorming and reflection tactics by improvement leaders may increase the implementation of ideas that improve patient experience.

Published Articles:

  • Lee YSH, Cleary PD, Nembhard IM. Effects of Leader Tactics on the Creativity, Implementation, and Evolution of Ideas to Improve Healthcare Delivery. J Gen Intern Med 2021. 36: 341–348. https://doi.org/10.1007/s11606-020-06139-9
  • Nembhard IM, Buta E, Lee YSH, et al. A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers. BMC Health Serv Res 2020. 20(137). https://doi.org/10.1186/s12913-020-4986-0
  • Lee YSH, Nembhard IM, Cleary PD. Dissatisfied Creators: Generating Creative Ideas Amid Negative Emotion in Healthcare. Work and Occupations 2020. 47: 200-227.
  • Lee YSH, King MD, Anderson D, Zlateva I, Cleary PD, Nembhard IM. The How Matters: How Primary Care Provider Communication with Team Relates to Patients’ Disease Management. Medical Care 2020. 58(7): 643-650.

Related Resources: 

Research Team: Yale

 

Improving Patient Experience with Hospital Care

Aim/Purpose: Burnout among nurses negatively impacts patient care experiences and safety. Inpatient pediatric nurses are at high risk for burnout due to high patient volumes, inadequate staffing, and needing to balance the demands of patients, families, and team members. Using data from a cross-sectional survey of nursing staff, the research team examined the associations of inpatient pediatric nurse burnout with their perspectives on patient experience measurement, quality improvement (QI), and unit culture, including the adequacy of staffing. Partnering with a different large, free-standing children’s hospital, the team is further examining these relationships with burnout across all pediatric staff.

Key Findings from Initial Study:

  • Nurses who had more confidence in patient experience measurement, received frequent patient experience performance reports, felt included in QI, and experienced QI efforts as integrated into patient care reported not being burned out (compared to those reporting burnout).
  • More open communication among nurses (e.g., about possible problems with care) and unit-level teamwork were also associated with not being burned out, whereas a larger QI workload was associated with burnout.

Key Questions for Current Study:

  • What aspects of QI involvement reduce burnout in the inpatient pediatric setting?

Published Articles:

  • Quigley, D.D., Elliott, M. N., Slaughter, M. E., Lerner, C., E., Hays, R.D. Narrative Comments About Pediatric Inpatient Experiences Yield Substantial Information Beyond Answers to Closed-ended CAHPS Survey Questions. Journal of Pediatric Nursing 2024;0(0). [In press]. 
  • Quigley, D.D., Slaughter, M. E., Hays, R.D. 2023. Pediatric Inpatient Leaders’ Views Changed with COVID-19: A Call to Re-engage in Quality Improvement. Pediatric Quality and Safety 8(3): e648. DOI: 10.1097/pq9.0000000000000648. 
  • Quigley DD, Slaughter ME, Qureshi N, Gidengil C, Hays RD. Associations of Pediatric Nurse Burnout with Involvement in Quality Improvement. Journal of Pediatric Nursing 2022. Nov 16:S0882-5963(22)00270-6. Epub ahead of print. doi: 10.1016/j.pedn.2022.11.001. PMID: 36402601.

Research Team: RAND

Aim/Purpose: This study focuses on the emotional dimension of patient experience during hospitalization. It will utilize new closed-ended and new open-ended survey questions that are designed to assess:

  1. The nature of emotional threats during care.
  2. The availability of emotional support to patients and their families.
  3. The proportion of emotional experiences identified by the new close-ended questions that overlap with those described in responses to open-ended questions.
  4. How emotional traumas might have been more affectively addressed by hospital staff.

This information will be used to design an organizational intervention to improve the emotional experience of care.

Key Questions

  • What are patients’ emotional experiences during their hospitalization (e.g., anger, sadness, joy, frustration, etc.) and are there differences among racial and ethnic groups?
  • What kinds of emotional support do patients receive during their hospitalization from hospital teams (e.g., Nursing, Spiritual Care, Social Work) and from those outside of the hospital (e.g., religious leader, family, and friends)?
  • Are there associations between patients’ satisfaction with their hospitalization, their emotional experiences, and emotional support? If so, what are they?
  • How much does the conventional open-ended question sequence in experience surveys elicit experiences related to emotional aspects of hospitalization, care, and support, and how do those elicitations compare to elicitations from new emotion-specific questions?
  • How can hospitals partner with patients to ideate on how hospitals can better care for patients’ emotions during hospitalization? Does a resulting intervention improve the emotional experience of care?

Research Team: Yale

Aim/Purpose: The goal of this study is to examine the use and value of data from the CAHPS Child Hospital (Child HCAHPS) Survey for improving pediatric inpatient use.

Key Findings:

  • Hospital quality leaders and staff believed that the Child HCAHPS Survey results accurately reflected their hospital’s quality of care, provided specific information for quality improvement, and could be used to improve pediatric care experiences.
  • A large portion of the comments from the single open-ended item contained sufficiently specific information about what needs to happen to improve care.

Published Articles:

  • Quigley, D.D., Elliott, M. N., Slaughter, M. E., Lerner, C., E., Hays, R.D. Narrative Comments About Pediatric Inpatient Experiences Yield Substantial Information Beyond Answers to Closed-ended CAHPS Survey Questions. Journal of Pediatric Nursing 2024;0(0). [In press]. 
  • Quigley, D.D., Slaughter, M. E., Hays, R.D. 2023. Pediatric Inpatient Leaders’ Views Changed with COVID-19: A Call to Re-engage in Quality Improvement. Pediatric Quality and Safety 8(3): e648. DOI: 10.1097/pq9.0000000000000648. 
  • Quigley DD, Slaughter ME, Gidengil C, Palimaru A, Lerner C, Hays RD. Usefulness of Child HCAHPS Survey Data for Improving Inpatient Pediatric Care Experiences. Hospital Pediatrics 2021. 11(10): e199-e209. doi: 10.1542/hpeds.2020-004283. PMID: 34548390.
  • Quigley DD, Palimaru AI, Lerner C, Hays RD. A Review of Best Practices for Monitoring and Improving Inpatient Pediatric Patient Experiences. Hospital Pediatrics 2020. 10(3), 277-285. doi.org/10.1542/hpeds.2019-0243. Epub 2020 Feb 18. PMID: 32071119.
  • Quigley DD, Predmore Z. What Parents Have to Say: Content and Actionability of Narrative Comments from the Child HCAHPS Survey. Hospital Pediatrics 2021. 12(2): 1-15. doi: 10.1542/hpeds.2021-006032.

Research Team: RAND

Aim/Purpose: The goal of this study was to evaluate the use and value of a six-item open-ended Narrative Item Set in development for the CAHPS Child Hospital Survey. The content and actionability of comments from this item set were compared to the content and actionability of comments from the single open-ended item that is standard in the CAHPS Child Hospital Survey.

Key Findings

  • Responses to the Narrative Item Set had nearly six times the word count of responses to the single item. Three quarters of those who received the item set provided responses to five or six of the questions.
  • Compared to the responses to the single item, more of the comments in response to the item set were deemed actionable. The question asking what a parent wished had gone differently elicited the most actionable narratives.
  • The multi-item, structured item set elicited a high percentage of comments with sufficient detail to inform improvements.

Published Articles:

  • Quigley DD, Elliott MN, Slaughter ME, Lerner C, Hays RD. Narrative comments about pediatric inpatient experiences yield substantial information beyond answers to closed-ended CAHPS survey questions. Journal of Pediatric Nursing 2024 Mar 2. https://doi.org/10.1016/j.pedn.2024.02.016.
  • Quigley DD, Predmore Z. Parents Have More to Say: Comments from the Child HCAHPS Single Question vs a Narrative Item Set. Hospital Pediatrics 2023. e2022007046. https://doi.org/10.1542/hpeds.2022-007046.

Research Team: RAND

Page last reviewed August 2024
Page originally created October 2023

Internet Citation: Research on Improving Patient Experience. Content last reviewed August 2024. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/cahps/quality-improvement/research/index.html

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