This committee work product has not been approved by ASA's Board of Directors or House of Delegates and does not represent an ASA Policy, Statement or Guideline.
This product was developed by the ASA Committee on Performance and Outcomes Measurement (CPOM) Patient Satisfaction workgroup. Contributors included: James Mesrobian, M.D., FASA (Workgroup Lead), Sheila R. Barnett, M.D., FASA, Karen B. Domino, M.D., M.P.H., David Mackey, M.D., Sonya Pease, M.D., M.B.A., Richard Urman M.D., M.B.A. The authors may be contacted via the ASA Department of Quality and Regulatory Affairs at email@example.com.
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1) EXECUTIVE SUMMARY
The ASA Committee on Performance and Outcomes Measurement (CPOM) is pleased to present an updated version of the ASA White Paper on Patient Satisfaction. The first White Paper, published in 2013, focused upon existing tools to measure patient satisfaction, the challenge of linking patient satisfaction measurement with patient outcomes, and the limitations inherent in measurement of patient satisfaction. This new paper builds upon those ideas yet also recognizes that there are new factors driving the need to measure patient satisfaction and that measurement of patient satisfaction carries value even if the process is not statistically valid or clearly linked with patient outcomes. These new factors include the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation, the ongoing rise of consumerism, and the increasing need to include measurement of patient satisfaction in facility and practice service agreements. The options available to measure patient satisfaction also have grown, and this paper includes a list of available practice-based and facility-based tools.
The Committee anticipates that this revised White Paper will be a valuable resource to all ASA members, regardless of practice size, model or resources.
In 2013, when ASA published the first ASA White Paper on Patient Satisfaction, the Centers for Medicare & Medicaid Services (CMS) and other entities already had started to prioritize measurement of patient satisfaction in general as well as in the perioperative period.
- The Agency for Healthcare Research and Quality (AHRQ), in collaboration with CMS, had produced a family of CAHPS surveys (Consumer Assessment of Healthcare Provider and System), covering multiple clinical settings.
- The most notable survey, the Hospital CAHPS (HCAHPS), had been used since 2008 as a component of the Value-Based Purchasing Program (VBP), with survey results linked to hospital payment updates.
- In 2011, the U.S. Department of Health and Human Services (HHS) partnered with the National Quality Forum (NQF) to establish the Measures Application Partnership (MAP). The MAP was charged with identifying gaps in performance measures and to provide input to HHS on the selection of future measures. MAP’s guiding framework emphasized the need for measures of patient experience, functional status, shared decision-making and care coordination.
- In 2013, CMS called for information to aid in the design and development of a survey regarding patient experience with hospital outpatient surgery departments/ambulatory surgery centers and patient-reported outcomes from surgeries and procedures performed in these settings, setting the stage for what at present is the Outpatient and Ambulatory Surgery (OAS CAHPS) survey.
Regulatory and legislative emphasis on measurement and reporting of patient satisfaction and linking of patient satisfaction to both hospital and physician payment has continued to grow since 2013. The ASA CPOM was tasked with updating this paper, specifically with respect to a) describing more clearly the factors that currently drive measurement of patient satisfaction and b) providing ASA members an idea of options that are available to measure and report patient satisfaction.
3) RATIONALE FOR MEASUREMENT OF PATIENT SATISFACTION AND ANESTHESIA
A. PROVIDING MARKET-DRIVEN CARE
The convergence of consumerism, technology and marketplace-oriented health policy is now rapidly transforming U.S. health care into a retail environment. Everyone, including patients, payers, employers and other stakeholders, is now looking for the best deals in health care, meaning lowest cost and easiest access with acceptable quality.
With increasing amounts of consumer information available on the internet, patients – now considered by many as value-driven consumers – are routinely shopping for value, quality, affordability and accessibility in their health care. Since procedural care is relatively easy to define, with a specific beginning and end, shopping for a range of procedural care may be comparable for some patients as shopping for a new television, car or house. Some patients now use the internet to search for the best combination of acceptable quality, low cost and purchase/delivery convenience for their health care needs.
Until very recently, medical decision-making was almost entirely in the hands of physicians. However, the proliferation of retail medical information on the internet is rapidly shifting decision-making towards the informed patient. Patients can now shop for medical care, laboratory and imaging studies, and procedures, giving them some control over their out-of-pocket costs and medical decision-making.
A good patient care experience with anesthesia helps create both patient loyalty to, and a competitive edge for, the health care organization. A better understanding of the subjective non-clinical patient experiences that come out of patient surveys can play a crucial role in patient and family decisions around where they will seek care again in the future. The similar paradigm holds true for large employers and health plans seeking strategic partnerships with a health care organization.1 The bottom line is patients, like any other consumer group, value not just the care they receive but also how they are engaged and communicated to throughout their health care experience. Health care organizations and clinicians involved in patient care should thoughtfully reflect on the results of patient satisfaction surveys and make the changes necessary to achieve results that bring the most value from the patient’s perspective.
While patients and consumer groups are asking for greater price transparency, competitive pricing and easy access to care, physician anesthesiologists have the unique role of communicating with their patients the quality and value of care a patient should expect to receive. Shared decision-making between a physician and patient may lead to better patient comfort and understanding with their medical care, expectations of patient recovery and any available follow-up communication between the patient and the anesthesiologist.
Physician anesthesiologists have the ability to use technology to assess patient needs before, during and after a procedure and should be mindful of patient expectations and outcomes. Patient navigation mobile device software is increasingly used to prepare the patient for his/her procedure and for post-procedure follow-up. In this manner, patients can much more easily receive education, ask questions and report problems prior to, and following, their procedures. Patient-generated information reported via these devices and apps can be shared or allowed access to by members of the patient’s care team. Patient navigation devices and portals seek to increase consumer convenience and satisfaction with their care and decrease health care provider costs by effectively managing personnel involvement pre- and postoperatively.
Many believe that traditional customer satisfaction surveys are relatively ineffective in providing useful information for increasing service or product value, and those satisfaction surveys assessing the often-anonymous anesthesiologist or anesthesia care team are probably even less helpful. Instead, we should be looking at ways in which we can improve patient satisfaction via improvements in access, service, and cost. Through care coordination, anesthesiologists are well-positioned to improve patient access, reduce costs, and ultimately increase patient satisfaction.
The most efficient and rational way for anesthesiologists to increase patient satisfaction is not to spend significant effort on marginal increases in most anesthesiologist-specific quality indicators, but to focus holistically on increasing access, improving service and decreasing costs throughout the periprocedural continuum. This non-traditional role will become more obvious and more available as health care organizations retool from silos related to educational backgrounds (surgeons, anesthesiologists, nurses, etc., each in separate departments) to patient-centered interdisciplinary teams (e.g., those surgeons, anesthesiologists and nurses within an institution who care for cardiovascular surgery patients, or GI surgery patients, or orthopedic surgery patients). Such reorganization to patient-centered interdisciplinary teams will much more readily facilitate bundling for contracting, billing and payments, as well as perioperative risk management, quality improvement and resource utilization. Anesthesiologists will find great opportunity in such interdisciplinary teams to impact access, quality, costs and thus, periprocedural patient satisfaction, if they will look beyond the operating room and pain clinic to help increase patient access, streamline patient throughput, and moderate care costs.
B. ALIGNING ANESTHESIA SATISFACTION WITH HOSPITAL VALUE AND QUALITY GOALS
With hospitals at risk of losing up to two percent of their Medicare revenue or potentially capturing additional revenue averaging $4 million for the average 250-bed facility if they perform in the top quartile on patient experience measures as determined by HCAHPS scores, it’s no wonder that health care executives rank patient experience and satisfaction as one of their top three priorities.2,3 Because many of the questions asked on these surveys target the patient’s perception of nursing and physician care and communication as well as the hospital environment and experience, it is easy to understand why many hospitals have made patient satisfaction a key performance indicator for physicians and physician practices. For some practices, hospitals have used HCAHPS scores as part of the anesthesia group’s service agreement, adding both financial risk and incentives to ensure alignment on HCAHPS performance.
From an anesthesia practice management standpoint, it is valuable to establish individual and/or group performance around patient satisfaction to drive performance improvement internally in order to optimize practice revenue. But the value of assessing patient satisfaction with anesthesia has economic impact not only to the anesthesia practice, but also to the health care organization. A good example is the perioperative surgical home concept (PSH), which integrates patient-centered, team-based procedural care from the time of initial diagnosis to the patient’s return to his/her primary care practitioner, is ideally suited to the retail patient care transformation currently underway. Clinical and financial risk assessment and modification, care coordination, bundled charges, pricing transparency, marketing, quality management, and outcomes assessment are all facilitated by the PSH. In addition, the PSH facilitates entrepreneurial partnerships between procedural providers to drive down prices, improve care access, and increase patient satisfaction. This intellectual capital required for procedural care transformation represents an opportunity to return to physicians much of the traditional decision-making power and autonomy they have lost or ceded to hospitals and insurance payers.
Feedback from patient satisfaction surveys often represents a patient’s perception of their care but may not necessarily reflect the quality or safety of the care they actually receive. There are few conclusive studies to date that correlate in a linear fashion high patient satisfaction scores with improved performance on surgical outcome measures.4 In the 2015 study, Sacks described a significant association between patients treated at hospitals with higher satisfaction scores with lower rates of postoperative mortality, lower rates of failure to rescue, and lower rates of minor complications. But at the same time, lower patient satisfaction was not demonstrated when either major surgical complications occurred, or hospital readmission was reported.5 This mixed review suggests that patient satisfaction is not simply a reflection of the quality of care received but may result more from individual factors including patient expectations and overall engagement in decision-making. Although patient satisfaction scores may not reflect the quality of the care received in terms of measurable outcomes or complications, these surveys nonetheless promote better communication with patients and families about care within the facility and improved engagement with patients on discharge planning resulting in shorter admissions to skilled nursing facilities and fewer hospital readmissions. The combination of these factors linked with patient satisfaction surveys can impact the overall costs associated with the episode of care.6,7
Reducing the chance of a lawsuit or other complaint is a high priority among many physicians and hospitals. The likelihood of a malpractice lawsuit among physicians is high; 42 percent of physicians will experience the stress and distress of going through a malpractice lawsuit at some point in their career.8 Measurement of patient satisfaction enables practices to understand more clearly how patients perceive their care; survey data can lead to insightful changes in physician behavior, patient care environment and patient workflows that improve patient satisfaction and possibly decrease the likelihood of a lawsuit. There is some evidence at the hospital level that higher patient satisfaction scores correlate with reduced incidence of legal action: in one study, hospitals who performed in the top quartile for patient satisfaction had the lowest incidence of lawsuits compared to hospitals that performed poorly on patient satisfaction surveys.9
Measurement of patient satisfaction is particularly challenging for anesthesiology practices. As noted in the first white paper, the majority of patient satisfaction studies do not use validated instruments to measure patient satisfaction, making comparison of results across facilities or practices very difficult. In addition, many patient experience measures have a narrow focus and do not reflect or capture the value provided by anesthesiologists over the entire perioperative period. Increasingly many surveys assume that value, as reflected by clinical outcomes, already exists. Instead, patient satisfaction increasingly is based upon shared decision-making and patients’ perceptions of care where value is determined from the perspective of the patient with respect to service and time.
C. ALIGNING ANESTHESIA PRACTICE GOALS WITH REGULATION
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Passed by Congress with near unanimous support in 2015, MACRA broadly and significantly is changing how Medicare pays physicians. While much of the content and implementation of this complex law remain uncertain, MACRA purposefully shifts payment toward benchmarked performance on multiple quality measures, including patient satisfaction, that assess individuals or group practices.
A full review of MACRA is not warranted for this review. In essence, MACRA established the Quality Payment Program (QPP), a new Medicare value-based reimbursement system. The QPP rewards physicians and clinicians for giving better care (improved outcomes), not just more care (volume) and aligns Medicare payments with quantifiable performance and quality metrics. By 2019, MACRA will eliminate existing value-based payment programs and establish two new pathways under the Medicare QPP:
- MIPS (Merit-based Incentive Payment System)
- APM (Alternative Payment Models)
Anesthesiologists can receive credit for implementing and scoring patient satisfaction measures and activities under both programs. While there is no mandate yet to report specific patient satisfaction measures for payment, opportunities to receive credit exist, specifically in the MIPS Quality and Improvement Activities categories. Patient satisfaction measures are one path by which anesthesiologists can satisfy MACRA’s value-based mandates and qualify for incentive-based payments under MIPS.
CMS is continuing to align facility-based clinicians with their health care facilities through the facility-based scoring mechanism described in the 2019 QPP rule.10 For facility-based clinicians, CMS will use the clinician’s facility score under the Value-Based Purchasing Program as a proxy for the MIPS quality and cost component scores. If the physician or practice also submits quality measure data, CMS will use the higher of that score and the facility’s VBP score for the physician or group practice. This opportunity may foster a sense of shared responsibility for patient outcomes requiring alignment with other facility-based physicians and the facility where they work for mutual benefit.
4) SURVEY TYPES AND OPTIONS
Anesthesiologists can assess patient satisfaction with anesthesia care by either facility-based surveys or anesthesia practice-based surveys. There are important benefits and limitations to each type of survey. Although they often lack scientific rigor and validation, anesthesia practice-based surveys more comprehensively can be used to evaluate and benchmark patient satisfaction with anesthesia services. For a comprehensive review of patient-satisfaction measures in anesthesia, please see Barnett et al.’s qualitative systematic review.11
Well-validated surveys are suitable for benchmarking at a national level, but usually require a third party to administer the survey, collect patient responses, and provide reports to anesthesia services. Though locally-instituted practice-based surveys can only be used to assess performance but are less costly. In order to provide benchmarking necessary for physician payment under MIPS and as quality incentive metrics reported to health care facilities and payers, facility-based surveys are recommended. However, lower cost anesthesia practice-based surveys also may support practice negotiations for anesthesia payments within APMs including accountable care organizations, bundled payments for procedures and the PSH.
A. FACILITY-BASED SURVEYS
Facility-based surveys are used by all hospitals and ambulatory centers to evaluate patient satisfaction. Examples of these surveys include the CAHPS survey focused on health plans, the OAS CAHPS focused on outpatient and ambulatory surgery, and the HCAHPS focused on other health care facilities.12,13 Press Ganey™ is the largest and most prominent patient experience vendor, used by more than 50 percent of hospitals. Press Ganey utilizes HCAHPS survey questions as well as additional patient experience questions.
Facility-based surveys are often customized to service lines and care settings and include the official CAHPS program questions, as well as some additional patient experience questions. Though the OAS CAHPS surveys includes several questions relevant to anesthesia care, CAHPS surveys in general do not include questions related specifically to patient satisfaction for anesthesia services and thus may not be suitable for benchmarking. This gap is particularly concerning given increasing ties between anesthesia care and anesthesia payment linked to MACRA-based performance measures, including patient satisfaction. An advantage of the standard facility-based surveys, on the other hand, is that they may more accurately reflect patient experience given inclusion demographic and case-mix variables.
B. ANESTHESIA PRACTICE-BASED SURVEYS
Anesthesia practice-based surveys are newer and may have less established scientific rigor than facility-based surveys. Survey questions, however, are more likely to focus specifically upon anesthesia care. Anesthesia practice-based surveys may be either administrated by vendors or locally without use of vendors. Examples of vendor-administered surveys include Survey Vitals™, ePreop’s AnesthesiaValet™ and AQI Quality Concierge®. These surveys are approved by CMS for reporting data on AQI48 to a Qualified Clinical Data Registry (QCDR), such as AQI NACOR, and can therefore be used for national benchmarking and pay-for-performance with MIPS. Locally-developed practice-based surveys lack national benchmarking but cost less to implement and still can be used to assess patient satisfaction within the health care facility and particular anesthesiology practice.
Table 1 lists some facility-based and anesthesia practice-based survey tools and their characteristics. Costs related to surveys included in Table 1 vary.
TABLE 1: Comparison of Select Patient Satisfaction Surveys
||CAHPS for MIPS
|Relevance to anesthesia care
general information only
general information only
general information only
|Benchmarking for Anesthesia
|# Questions RE: Anesthesia Providers
* ePreop™ includes NACOR Quality Concierge™ and Anesthesia Valet™
** 6 questions overlap with surgeon and facility
***25 questions if care team
****Vendor contact information in Appendix A
A. SUBMITTING PATIENT SATISFACTION SURVEYS UNDER MIPS
In the MIPS Quality category, many of the available patient satisfaction measures focus upon specific disease states (i.e., psoriasis, osteoarthritis) that are not related to anesthesia care. Nevertheless, there are two specific options for anesthesiologists to report patient satisfaction measures via the Quality category.
- CAHPS for MIPS: Physician practices seeking to receive credit for this measure must engage a vendor designated by CMS. The 2018 CAHPS for MIPS contains 10 summary survey measures that assess getting timely care, appointments and information as well as a patient’s rating of providers, access to specialists and shared decision making, among others. In CMS documents, the agency cautions that “CAHPS for MIPS survey may not be appropriate for groups that do not provide primary care services.”14 Anesthesia practices should review the CAHPS for MIPS criteria and questions for applicability to their practice before contracting with a CAHPS vendor.
- AQI 48 (Patient-Reported Experience with Anesthesia): This measure was developed by ASA and focuses exclusively on anesthesia care. The measure builds off the work of the previous iteration of this paper and ASA’s Perioperative Surgical Home (PSH) Collaborative and is offered in the ASA’s Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (AQI NACOR) for reporting and benchmarking. A valid survey includes a core set of questions that address three of four specific criteria related to patient experience and satisfaction and one mandatory question related to rating overall experience. The four criteria and mandatory question are described below.
- 1. Preoperative Education and Preparation
- 2. Patient and/or Family Communication
- 3. Care Team Response to Comfort and Well-Being
- 4. Postoperative Pain Control and/or Management
- Mandatory question that must be included in each valid survey (practices must also include an option for patient to indicate “Not Applicable”): On a scale of 1 to 5, where 1 indicates the worst anesthesia experience and where 5 indicates the best anesthesia experience, how would you rate your overall anesthesia experience?
In the MIPS Improvement Activities (IA) category, there are numerous options for anesthesiologists to attest to patient satisfaction (See Table 2). Participation in CAHPS surveys or in QCDRs that assess patient engagement can be reported as a MIPS IA. Practices should recognize that there are specific requirements for processing, timing and record-keeping of reported surveys. To meet the criteria for attesting to a patient satisfaction IA, practices must:
- Use a third-party vendor to administer and collect surveys
- Keep detailed records as CMS can audit attestations and activities
- Administer surveys for at least 90 days
TABLE 2: MIPS 2018 Improvement Activities Related to Patient Satisfaction
MIPS Improvement Activities may change from year-to-year. For an up-to-date list of IAs and complete criteria for attestation, please visit https://qpp.cms.gov.
|Improvement Activity (2018)
||Activity Description (2018)
|IA_EPA_3: Collection and use of patient experience
and satisfaction data on access
|Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
|IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
||Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
|IA_PSPA_11: Participation in CAHPS or other supplemental questionnaire
||Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).
|IA_PSPA_18: Measurement and improvement at the practice and panel level
||Abridged: Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel).
Table 3 summarizes common patient satisfaction surveys and their applicability to requirements for reporting to MIPS under Quality or IA.
TABLE 3: Patient Satisfaction Surveys to Fulfill MIPS Requirements
||ePreopTM Anesthesia ValetTM
|MIPS Quality: AQI48 (Survey must meet measure specifications)
|MIPS Quality: CAHPS for MIPS* (CMS has designated more than a dozen vendors to collect CAHPS for MIPS surveys)
|MIPS Improvement Activities (Must meet data validation criteria)
||BE_6, EPA_3, PSPA_11
||BE_6, EPA_3, PSPA_11
||BE_6, EPA_3, PSPA_11**, PSPA_18
||BE_6, EPA_3, PSPA_11**, PSPA_18
||BE_6, EPA_3, PSPA_18
*Participation in CAHPS for MIPS fulfills one of the six measures required in the MIPS Quality Component.
**Use CAHPS survey for this Improvement Activity.
Though at present there is no Federal requirement for anesthesiologists to report patient satisfaction surveys as a condition of payment, practices may wish to align their goals and quality improvement activities with available national patient satisfaction metrics. Practices should be aware that the links between patient satisfaction measurement and payment within the regulatory and legislative spheres continue to strengthen. Given the evolving link between hospital payments and performance on CAHPS surveys, anesthesiologists may wish to include patient satisfaction measures in individual employment agreements and/or system contracts for anesthesia services. Anesthesiologists also may wish to include patient satisfaction measures as part of a potential quality incentive bonus in bundled payment contracts. The American Society of Anesthesiologists (ASA) continues to work with payers, vendors and other national specialty societies to define and more clearly acknowledge anesthesiologists’ contributions to patient satisfaction throughout the episode of perioperative care. Anesthesiologists also may wish to develop local practice-specific patient satisfaction tools that do not utilize an external vendor but nevertheless align with national patient satisfaction measurement metrics.
There is no universally agreed-upon definition of "patient satisfaction" as patient satisfaction is a multidimensional experience which is likely not amenable to one-dimensional unvalidated assessment tools often used for assessment of satisfaction.15,16
Despite the large numbers of studies on patient satisfaction with anesthesia services, many lack the psychometric testing and design to determine their validity as measures of patient satisfaction.17,18,19,20 The studies utilized as source material by the ASA CPOM were evaluated on the strength of their validity; however, only eleven studies met inclusion criteria and only three of the studies were performed using subjects in the U.S. Furthermore, the statistical validation of the studies evaluates the survey instruments as a whole. Selecting questions from various valid survey instruments does not a priori produce a new valid instrument. Nor is there a guarantee that combining the short list of questions with a larger survey instrument will yield a valid study. However, selecting the questions from the previously validated instruments may lend some evidence of face and construct validity – the concept that the survey is measuring the right things. With sufficient data collection through AQI, the recommended survey questions can be further studied for validity (e.g. internal question consistency) and reliability. Anesthesia practices that report patient satisfaction data to the AQI will have the opportunity to access educational materials from ASA, including both CME for anesthesiologists and multi-media information for patients.
Timing of the Survey
Standardization of the timing for delivery and return of surveys will help in evaluating comparisons. Increasing length of time between anesthesia care and the administration/return of the survey can affect results, and studies have shown a direct relationship between the encounter and timing of the survey.21,22 This can be due to several factors including recall bias. It has also been shown that as more time progresses satisfaction scores correlate with the outcome of the procedure.23 For example, as time progresses and it is apparent to the patient that his or her knee surgery was a failure, the patient will be more likely to be dissatisfied. Unfortunately, the optimal timing of survey administration after surgery has not been determined for either surgeons or anesthesiologists. Based on expert opinion, CPOM determined that the survey should be administered as close to the patient encounter as possible, preferably within two weeks of discharge.
Several important factors need to be taken into consideration with creating and evaluating the surveys. These factors include, but not limited to, lack of correlation between patient experience and patient outcomes, physician resistance to link patient experience with payment and patient bias in filling out surveys. First, it is important to make distinctions between patient experience and other potentially cross-cutting measures as they can impact satisfaction scores. Surveys should distinguish between a patient’s experience of the care process and patient-reported outcome measures. Some common and potentially overlapping patient-reported measures that can affect patient satisfaction scores may include patient perceptions, patient engagement, patient participation, and patient preference.24 It is also important to note that studies of the relationship between patient satisfaction and health care quality and outcomes have produced mixed results, some showing positive, while others showing either negative or no association.25
Oftentimes, there is also physician resistance to link patient satisfaction with payment, whereas in other cases patients may be guided to respond in a particular way when filling out the survey. Practices should try not to bias patients on survey responses but instead use standardized instructions to accompany the survey request. The creation of satisfaction metrics can be difficult due to the interrelation between health status as a result of treatment and satisfaction with care. This means that data on satisfaction may not be interpreted independently of the information on health.16,17
Case Mix Adjustment and Patient Related Determinants of Satisfaction
We have described the importance of including patient factors in the survey instrument because they can influence patient satisfaction independent of care. Much in the same way that predicted morbidity and mortality after cardiac surgery must be “adjusted” for patient factors like prior cardiac function, patient satisfaction can be significantly influenced by patient factors. Patient factors can influence satisfaction scores, such as age, gender, race, education, socioeconomic status and perceived health status. Increasing age and fulfillment of the patient’s immediate needs (regardless of long-term benefit) has been shown to be associated with more favorable satisfactions scores. Conversely, poor health status is associated with dissatisfaction.
Current surveys of patient experience generally do not adjust for patient socioeconomic and demographic factors. Several problems exist with regard to these observations and it is not known how or why these factors play a role. For example, some studies have shown it is possible that providers may interact with older or female patients differently.18 In addition, there is insufficient research regarding the statistical case-mix adjustment models that can be appropriately used to adjust patient satisfaction scores.19 Other patient factors (e.g. alcohol or substance abuse, preoperative pain score) may play a significant role as well. Additional research will be necessary to further define patient determinants of satisfaction and to develop the necessary statistical models to adjust patient satisfaction scores. This work is necessary to increase physician confidence in survey scores, particularly in a high-stakes environment.
Measurement of patient satisfaction remains one of the most challenging and sometime confusing tasks for anesthesiologists. While there are legitimate concerns about survey reliability and validity, it is increasingly clear that there is increasing demand from hospitals, patients and payers that anesthesiologists assess patient satisfaction with their clinical care and their service. Compared to 2013, anesthesiologists now have an increasing number of practice-based and facility-based options to measure patient satisfaction and provide feedback to their clinicians and other key stakeholders.
Appendix A: CMS-Approved Vendors for MIPS Patient Experience Surveys
1. MIPS 2018 CAHPS CMS Approved Survey Vendors
- Axxess: www.axxess.com/research
- Center for the Study of Services: www.cssresearch.org
- DataStat, Inc.: www.datastat.com
- DSS Research: www.dssresearch.com
- Management and Technology Consultants: www.mtchealth.com
- Novaetus Inc., A SurveyVitals Company: www.novaetus.com
- NRC Health: www.nrchealth.com
- Percy & Company: www.percyandcompany.com
- Press Ganey: www.pressganey.com
- Professional Research Consultants: www.prccustomresearch.com
- Research & Marketing Strategies, Inc.: www.rmsresults.com
- SPH Analytics: www.sphanalytics.com
- SullivanLaullin Group: www.sullivanluallingroup.com
- SurveyVitals, Inc.: www.surveyvitals.com
2. External vendors measuring patient experience
- Agency for Healthcare Research and Quality (AHRQ) CAHPS Surveys and Guidance: www.ahrq.gov/cahps/surveys-guidance/index.html
- AQI NACOR Quality Concierge/ePreopTM: www.asahq.org/macra/solutionsresources/aqisnacor/qualityconciergevendor
- ePreopTM Anesthesia Valet: www.epreop.com/anesthesiavalet/
- Press Ganey: www.pressganey.com
- Survey VitalsTM: www.surveyvitals.com
- Tasset D. The key to simplifying U.S. healthcare reform. Nuehealth website. https://nuehealth.com/key-simplifying-u-s-healthcare-reform/. Published March 6, 2018. Accessed August 8, 2018.
- Rice C. 5 ways to raise HCAHPS scores via staff engagement. Health Leaders Media. January 28, 2013. https://www.healthleadersmedia.com/strategy/5-ways-raise-hcahps-scores-staff-engagement. Accessed August 8, 2018.
- Hall MF. Looking to improve financial results? Start by listening to patients. Healthc Financ Manage. 2008; 62(10):76-80.
- Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg. 2014;260(4):592-600.
- Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality. JAMA Surg. 2015;150(9):858-864.
- Agency for Healthcare Research and Quality. Guide to patient and family engagement in hospital quality and safety. https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html. Published June 2013. Accessed August 8, 2018.
- Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
- Weiner J. How good patient satisfaction can reduce malpractice risk. Modern Medicine Network. June 4, 2018. http://www.physicianspractice.com/malpractice/how-good-patient-satisfaction-can-reduce-malpractice-risk. Accessed August 8, 2018.
- The Centers for Health Affairs. The growing focus on patient experience and why it matters. Northeast Ohio Hospitals website. https://neohospitals.org/~/media/CHA/Files/PPTs/Issue%20Brief%20PPTs/Patient%20Experience%20PPT.ashx. Accessed August 8, 2018.
- Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program--Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions from the Medicare Shared Savings Program--Accountable Care Organizations- Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. 42 CFR Parts 405, 410, 411, 414, 415, 425 and 495.
- Barnett SF, Alagar RK, Grocott MP, Giannaris S, Dick JR, Moonesinghe SR. Patient-satisfaction measures in anesthesia: qualitative systematic review. Anesthesiology. 2013;119(2):452-478.
- Outpatient and ambulatory surgery CAHPS survey. OAS CAHPS website. https://oascahps.org/Survey-Materials. Last updated November 2018. Accessed August 2018.
- Centers for Medicare & Medicaid Services. HCAHPS: Patients’ perspectives of care survey. CMS website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Last updated December 21, 2017. Accessed August 2018.
- Centers for Medicare & Medicaid Services. 2018 Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) survey via CMS-approved survey vendor reporting. CMS website. https://qpp-cm-prod-content.s3.amazonaws.com/uploads/152/2018%20CAHPS%20for%20MIPS%20Survey%20Approved%20Vendors.pdf. Published March 27, 2018. Accessed August 2018.
- Kraska RA,Weigand M, Geraedts M. Associations between hospital characteristics and patient satisfaction in Germany. Health Expect. 2016;20(4):593-600.
- Wazir A, Shukla A, Dutton RP. Patient satisfaction in anesthesia: implementation, relevance, and identification of meaningful measures. Adv Anesth. 2018;36(1):23-37.
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