Sharpening your survey skills: How practices can measure patient satisfaction

At some point, practice administrator Greg Bush expects to have Medicare surveying patients who go to Gastroenterology Consultants of Greater Cincinnati about their experiences. And, he said, he expects the survey results to become part of what determines the practice's Medicare pay.

Bush said he didn't know exactly what the Centers for Medicare & Medicaid Services had planned for patient satisfaction scores and pay-for-performance but knew enough to try surveying patients first. "I'd rather be ahead of it."

In fact, the Patient Protection and Affordable Care Act requires Medicare to include "an assessment of patient experience and patient, caregiver and family engagement" on Medicare's Physician Compare website by Jan. 1, 2013.

Experts say Medicare is likely to integrate that measurement of patient experience into a pay formula for physicians by 2015.

It already has begun requiring hospitals to report patient survey data to receive full payments. Beginning in 2013, hospitals' pay will depend on patients' reported experiences.

Many medical offices, like the practice Bush helps manage, already are asking patients for feedback. If payers are not already surveying patients and tying the results to payment rates, they will be soon.

Given the amount of potential money hanging in the balance, physicians have a new reason to design a survey themselves or choose a vendor to do it for them, experts said.

How best to do the preemptive surveying depends on a practice's budget, whether the physicians want to ask highly specific questions about the practice rather than standard ones, whether they are interested in benchmarking against physicians across the country, and how closely they are interested in mimicking payers' surveys.

First, physicians or group practices must decide whether to hire a vendor to conduct the surveys and analyze results.

A number of vendors offer online surveys analyzed with national benchmarking data.

Some vendors survey patients using questions similar to those in the survey instrument developed by the Dept. of Health and Human Services for physician offices, called the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey or CG-CAHPS.

But going with a vendor isn't the only way to use CG-CAHPS as a model -- the other option is to write your own survey using the document as a guide.

The practice can decide to conduct the survey either by paper or online.

A free downloadable version of the CG-CAHPS survey is available online and comes with instructions and methodology for analyzing the results.

The practice also could decide to ask its own questions, based purely on what it values and wants to know about.

Increasingly, medical practice Web designers are adding some form of patient survey to practice websites, said Elizabeth Pettrone, president and founder of Practis, a Charlotte, N.C.-based Web design firm that specializes in medical practice websites.

She said vendor-developed surveys were once popular among her clients, but many are turning to their own websites to host custom-written surveys.

"Five or six years ago, it was once out of a blue moon. Now it seems like 30% of them will ask for it," she said. Of the big vendors' sites, she said, "Some doctors liked having the comparative reporting to other physicians in their specialty. The downside is because they need to normalize the data, they have to keep the survey questions the same."

How to design a survey

One way for a practice to prepare for when Medicare administers CG-CAHPS is to start surveying patients independently, using the publicly available template.

The questions on the CG-CAHPS survey were developed with help from the American Medical Association and other interested parties. All questions are answered on a scale of "always" to "never." For example: "In the last 12 months, how often did this doctor show respect for what you had to say?"

Whatever questions physicians ask and whatever templates they choose, experts say, they should strive to make the survey as brief as possible while still eliciting meaningful responses.

That will help with another challenge -- getting surveys back. "The more concise you can make it, the better response rate you're going to have," said Gastroenterology Consultants' Bush.

Pettrone noted, large vendors keep their questions standard for a reason: If it's important to track performance over time, changing the questions significantly every time will make it difficult to identify improvement or decline in scores.

Pettrone suggested that questions be ordered chronologically. Start questions where the visit begins, or even before. How long did it take to find parking? How long was the wait before the patient was seen by a nurse? How did the front desk staff treat the patient? The questions can continue through the visit right to asking about follow-up care.

Physicians designing their own surveys also need to decide what kind of answers they want to elicit -- perception of experience, like the CG-CAHPS survey, or a rating of an experience, like what surveys by consulting firm Sullivan Luallin use. The San Diego-based firm is the preferred vendor of the Medical Group Management Assn.

Co-founder Meryl Luallin said the framing of the questions on the group's surveys is deliberately different from CG-CAHPS.

"Our rating scale is, 'How would you rate this? Excellent, very good, fair or poor?' That's markedly different from asking a patient to try to recall the actual experience they had," she said. "We don't believe a patient's memory going back six or nine months ago is very valid."

How to conduct the survey

Because results become more meaningful with a higher participation rate, better response rates mean better results. Many practices ask patients to visit either an online vendor survey or the practice's website after their appointment.

Experts differ about whether it is a good idea to have patients take a survey while they are in the office. Pettrone said her clients sometimes take an older computer, set it up in the waiting area and bring up the survey online so patients who don't have Internet access at home, or those who prefer to get it out of the way, can answer.

Steve Feldman, MD, PhD, a dermatologist who is CEO of DrScore.com, a Winston-Salem, N.C.-based company that sells online surveys, said some of his customers set up in-office kiosks, though he said, "I worry a bit about whether [patients] can fill it out totally honestly there."

But Pettrone said an in-office kiosk or computer probably is preferable to offering a paper survey, because paper questionnaires are so easily discarded or lost. "It's always a problem -- how do you get that paper back?" she said.

Even if filling out the survey online is easy, persuading patients to do it is another matter.

Alycia Ottesen, director of business development for medical services at South Bend, Ind.-based Press Ganey, which sells survey tools to doctors, said the best incentive is to show patients changes made in response to their feedback by posting information in the waiting area about survey results, and what's different based on their survey answers. The AMA and Press Ganey in October 2010 partnered to create an online patient satisfaction survey service called RealTime. It costs $65 per month for AMA members, $85 for nonmembers.

One way to encourage patients to fill the survey out is to stress how valuable their feedback is, Dr. Feldman said.

"The [physician] asking the patient is a really good way," he said. "Patients are really loyal to [physicians]. They want to do what's recommended. They want to please them."

Why surveying pays off

Every pay-for-performance program is different, as is every practice. And most programs depend on more than patient survey scores, so experts say it's difficult to quantify the financial rewards for surveying patients.

For Sharp-Rees Stealy physicians, for instance, the group of 400 employed physicians in San Diego affiliated with Sharp HealthCare brings in millions of dollars a year in pay-for-performance earnings, said Physician Champion for the Sharp Experience Steve Beeson, MD.

But that's a large group, and California's health insurers had some of the first and most active pay-for-performance programs. Even so, Dr. Beeson pointed out, the benefits of focusing on patient experiences, even the financial ones, extend beyond what payers give a practice with strong scores.

Happy patients will refer friends and relatives to their physicians, which improves market share and saves money on marketing, he said. Though money is what pays the bills, keeping patients coming in the door is paramount, and responding to patient feedback is the best way to retain them, Dr. Beeson said.

And there's the benefit of knowing what patients are thinking, and being able to identify what might improve the way the practice operates and cares for patients.

Practice administrator Bush put it another way: "If you're not going to use your satisfaction survey to fix things, then why bother doing it?"