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What does the patient know about quality?

Karen Luxford
DOI: http://dx.doi.org/10.1093/intqhc/mzs053 439-440 First published online: 22 August 2012

‘Hospitals aren't hotels’ and ‘Patients are seldom the best judges of their medical care’ read the letters to the New York Times Editor in mid-March 2012. Since this exchange of letters, debate has been raging about the value of the patient's views of care in relation to gauging quality. This debate has been spurred on in the USA by the approaching FY 2013 introduction of the Hospital Value-Based Purchasing programme including incentive payments for performance in patient care experience scores [1]. Patient experience will comprise 30% of the total bonus payments. The remaining 70% is for performance in the ‘clinical process of care’.

This debate has raised questions in the clinical community and quality improvement arena about the relationship between ‘perceptions of care’ and safety and quality.

The basic premise that focusing care around the patient and responding to patient's needs and preferences (‘patient centred care’) is a key domain of quality in healthcare has been established for over a decade [2]. Yet, many services still struggle to transform care to be patient-focused [3].

Accompanying the recognition of ‘domain of quality’ status has been an increasing interest in the patient experience of care is an indicator of quality. Measurement of quality, however, has traditionally focused on access issues and clinical care process through waiting times and disease-specific indicators or overall mortality (the ‘ultimate’ outcome) [4]. Inclusion of specific safety measures, such as ‘never events’, is a more recent addition.

We need to acknowledge, however, that quality in hospital settings is affected not only by the quality of technical care received, but also by the quality of the interpersonal relationships (both patient-to-staff and staff-to-staff) and the quality of the hospital amenities and environment [5]. Indeed, some of the debate around patient-centred care has shifted towards the need for care that is ‘relationship-centred’ [6]. Accepting that good quality is ‘more than just technical care’ necessitates not only broader measures of care quality, but the inclusion of such measures in the levers used to drive quality improvement.

Increasingly, evidence points towards good patient experience and good clinical quality going hand-in-hand. Several studies now indicate that hospitals that perform well on patient care experience surveys also do better on clinical metrics. In a study of over 306 hospital referral regions defined by the Dartmouth Atlas, hospitals with lower overall ratings by their patients also tended to have lower technical quality measures [7]. Jha et al. [8] concluded that hospitals with high levels of patient-reported ‘care experience’ provide clinical care that is higher in quality across a range of conditions. A number of papers have associated high patient ratings of experience of care with lower mortality in patients with acute myocardial infarction [9, 10] and with fewer hospital readmissions within 30 days after adjusting for clinical quality [11].

The debate about re-imbursement to health services based on patient perceptions of quality heated up with the publication of a paper which reported a link between higher ‘patient satisfaction’ scores and poorer outcomes [12]. These findings surprised many researchers in the field as they appeared to run contrary to a number of other studies and raised queries regarding methodological issues.

What about safety? Should we be listening to what patients say about hospital cleanliness? Indeed, it appears that we should as patient feedback is a positive predictor for staff participation in hand-washing and for methicillin-resistant Staphylococcus aureus (MRSA) infection levels—apparently a better predictor than feedback tools used with clinicians and managers [13, 14]. Compared with the worst-rated hospitals, the hospitals that received the best patient ratings on the UK's ‘NHS Choices’ website had 42% lower MRSA infection rates, 11% lower readmission rates and 5% lower mortality rates [15].

Again on the ‘predictive power’ front, patient surveys have been used to identify very poor performance in communication skills by doctors [16] and to predict malpractice risk [17]. Patient surveys consistently report the need for improvement in clinician communication skills and team work. Patient feedback can provide another early warning system for safety issues as patient perception of poor communication is associated with elevated adverse event rates. Health Grades 2012 America's Best Hospitals [18] reported that hospitals rated in the bottom 10% for ‘doctor communication’ reported 15% more patient safety events than the top 10% performing hospitals. This increased to 27% more patient safety events for those in the bottom 10% for ‘nurse communication’ compared with the top 10% performing hospitals. Catheter-related bloodstream infections occurred ∼56% more frequently in hospitals with low ratings for nurse or doctor communication [18].

It must be recognized, however, that surveys of patient experience are only one method for measuring patient perceptions of care. Indeed, the surveys are only as good as the questions asked. A distinction needs to be made between ‘satisfaction’ and learning from the patient ‘experience’ of care. Patient feedback about healthcare should capture the extent to which expectations of care have been attained. As consumers of healthcare services, we all start from a different level of anticipation [19].

In this Internet age, patients are increasingly expressing their views about the quality of healthcare and rating clinicians publically on websites—Patient Opinion, Angie's List, Healthcare Reviews, to name but a few. Interestingly, there is evidence that patient views expressed on websites correlate with ratings from conventional patient surveys [20].

The importance of capturing the whole experience of engaging with a service is a lesson learnt by other industries over a decade ago [21]. Even with ‘customer focus’ as a key domain of quality, healthcare has not yet fully embraced using patient feedback as a driver of quality improvement. The usefulness of patient experience surveys as tools is dependent not only on the collection of survey data but on the successful use of patient feedback to drive improvement [22]. In this endeavour, there are potential lessons to be learnt from health services that deliver a consistently better experience for patients [23].

We can debate whether we have the right tools and the proportion of each domain of quality that should be re-imbursed through pay for performance initiatives. However, we need to move beyond questioning whether the patient knows anything about quality care when they see it.

In the face of mounting evidence, improving patient experience is not only ‘nice’ but necessary.


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