Quality evaluations enhanced by patient feedback

Hospitals that hire Barbara Gerber to show up in a wig and pose as a patient to thoroughly document how well they treat their patients are willing to pay a premium for the service -- up to $25,000 for dozens of incognito visits and a voluminous report from the president of the health care mystery shopping firm Devon Hill Associates.

The bill from the La Jolla, Calif.-based company represents a hospital's investment in discovering what only patients can tell them about the quality of care: Whether patients feel they are listened to, treated with respect and able to share in medical decision-making.

"There's an interpersonal quality to patient care," said Gerber, a former hospital marketing director. "If people don't like the physician or nurse, that may have some serious implications" for the quality of care.

Mystery patients aren't new to hospitals or even physicians' offices. But there's a renewed focus to make patient-reported experiences a critical part of quality evaluations.

Most recently, the National Quality Forum in December 2005 endorsed a 27-question survey that attempts to measure patients' experiences. The Agency for Healthcare Research and Quality developed the questionnaire, named Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.

"There was some sense in the past that all patients cared about was the color of the walls and free parking," said Elaine J. Power, PhD, NQF's vice president of programs. Now, she said, hospitals and physicians appreciate that the core of a patient's health care experience can help quality improvement efforts.

In Gerber's case, documenting the patient experience goes beyond noting whether the nurse remembered to smile or the physician gently patted a shoulder. She and fellow mystery patients -- who are supplied with phony medical charts and outpatient orders by hospital physicians -- document issues as simple as a bed's guardrails not being raised after a patient complained of dizziness or as complex as appropriate triage care.

At one hospital's emergency department, Gerber presented as a 54-year-old woman with heartburn that had subsided. While the ED's intake clerk asked patients to tell a triage nurse if they were having certain heart attack symptoms, Gerber could not find one.

"I didn't get triaged for 30 or 35 minutes," Gerber said. "As a result, they changed their whole triage system." Similarly, NQF officials hope that patients' answers to the HCAHPS questions could help hospitals and physicians improve quality and patient safety. HCAHPS results are expected to be publicly available on the Centers for Medicare & Medicaid Services' Hospital Compare Web site (link) in 2007, Dr. Power said. Hospitals can volunteer to participate in the survey, which will be conducted via telephone and mail.

The survey asks patients three doctor-specific questions: Whether they believe physicians treated them with courtesy and respect, listened to them carefully and explained things in a way they could understand.

Although most quality improvement initiatives focus on clinical performance and safety measures, Dr. Power said the patient's perspective can aid those efforts.

"A patient experience-of-care questionnaire can actually be one of the ways of measuring whether those other parts of health care are being addressed," she said.

AHRQ is at work on a similar survey focused on ambulatory physician care that it hopes to present to NQF in March. Questions are expected to cover areas such as coordination of care, access to care and shared medical decision-making, said Beth Kosiak, PhD, senior social scientist at the AHRQ's Center for Quality Improvement and Patient Safety.

"There's some information critical to the health system and the practitioner that can only come from the patient," she said. "Studies are beginning to show that patients who rate their care experience more highly often have better clinical outcomes."

While there may not be a cause-and-effect relationship between patient-satisfaction ratings and health outcomes, the evidence shows a correlation, according to Dr. Kosiak.

"For example, if you rate your communication with a physician more highly, you're more likely to comply with what they say," she said.