539994

research-article2014

AJMXXX10.1177/1062860614539994American Journal of Medical QualityManary et al

Article

Organizational Characteristics and Patient Experiences With Hospital Care: A Survey Study of Hospital Chief Patient Experience Officers

American Journal of Medical Quality 1­–9 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614539994 ajmq.sagepub.com

Matthew Manary, PhD1, Richard Staelin, PhD1, Keith Kosel, PhD2, Kevin A. Schulman, MD3, and Seth W. Glickman, MD, MBA1,4

Abstract Beginning in fiscal year 2013, scores based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) constitute 30% of incentive-based payments from Medicare’s Value-Based Purchasing (VBP) initiative. Yet there is little empirical work to understand hospital approaches to improving the patient experience. In this study, chief patient experience officers at 416 VHA hospitals were surveyed to assess the relationship between organizational characteristics and publicly reported HCAHPS scores. Of 416 institutions, 143 (34.4%) participated. Respondents reported that boards (68%) and chief executive officers (81%) viewed the patient experience as extremely important. In contrast, they reported that in only 15% and 34% of hospitals, respectively, physicians and nurses were supportive of efforts to improve the patient experience. Hospitals with collaborative cultures and higher physician engagement had higher VBP total HCAHPS scores (6.9 points and 8.2 points higher, respectively; both P < .05). These areas should be addressed to improve the patient experience in provider organizations. Keywords patient experience, quality, health policy, value-based purchasing Beginning in fiscal year 2013, scores based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) constitute 30% of total incentive-based payments from Medicare’s Value-Based Purchasing (VBP) initiative.1 Beyond reimbursement implications, patient-centered care is increasingly viewed as being fundamental to increasing the value of health care delivery by improving quality and lowering costs.2-5 As a result, senior leadership at US hospitals has redoubled its efforts to improve the patient experience. In a national survey, 91% of hospital boards surveyed have specific goals for improving the patient experience, the highest among the 4 quality indicators surveyed.6 Yet there is little empirical work to understand the approaches that hospitals are using to improve the patient experience and whether these investments actually translate to higher HCAHPS scores. Previous work suggests that transforming the patient experience will require significant changes in organizational strategy, leadership, operations, and culture.7,8 A better understanding of these issues is critical to informing policy efforts to improve the patient experience and the transformation to valuebased care in provider organizations.

In this study, a novel survey was used among senior leaders at a national network of nonprofit hospitals, along with publicly reported HCAHPS-VBP scores, to (1) characterize management processes around the patient experience, including senior leadership and organizational goals, operations, and culture; (2) describe the association between organizational approaches aimed at improving the hospital’s HCAHPS measures and the independently obtained HCAHPS-based VBP scores; and (3) identify key factors believed to inhibit or enable the improvement of the patient experience in provider organizations.

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Duke University Fuqua School of Business, Durham, NC VHA Center for Applied Healthcare Studies, Dallas, TX 3 Duke Clinical Research Institute, Durham, NC 4 Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC 2

Corresponding Author: Seth W. Glickman, MD, MBA, Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB #7594, Chapel Hill, NC, 27599. Email: [email protected]

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American Journal of Medical Quality

Methods Survey Development This study was performed in concert with the VHA Center for Applied Healthcare Studies. VHA is a nationwide network of more than 1300 community-owned hospitals and health care systems. The survey was developed to test a series of hypotheses based on frameworks and empirical observations drawn from the medical and business literature and augmented with input from the research team and national experts in the patient experience.9-14 The questions were developed via an iterative process among the study authors and outside experts. On the basis of this process, the study team identified 3 key domains and associated questions for each: (1) seniorlevel leadership and its commitment to the patient experience, (2) operational activities (including mechanisms for information feedback, training, and incentives), and (3) organizational culture. The team also assessed perceived barriers and facilitators in each area.

Study Sample Among the 1300 VHA hospitals, the study team identified an initial target sample of 416 hospitals selected to be representative of all VHA hospitals with regard to geographic location and size. The team arrived at this sample size according to study resources and a priori sample size calculations. After identifying the specific hospitals to be sampled, a representative from each VHA regional office contacted each hospital to identify the name and contact information for the senior person responsible for overseeing the patient experience at that organization. The official title of this person varied widely across organizations. However, to maintain consistency throughout the article, this person is referred to as the “chief patient experience officer,” although his or her actual title may differ (Table 1).

Survey Administration Qualtrics was used to administer the survey to the target sample starting in January 2013. The chief patient experience officers received a survey invitation by e-mail, followed shortly thereafter by another e-mail containing a unique survey Web link. Electronic survey reminders were sent after 2 weeks, and follow-up telephone calls were made to nonrespondents after 1 month.

Patient-Reported Experience Scores To capture the patient experience and the financial implications, the survey results were merged with Hospital Compare’s publicly available HCAHPS-based VBP domain scores for each participating hospital. Hospitals are

scored in 3 ways: for their contemporaneous HCAHPS performance relative to other hospitals (achievement), their change over time (improvement), and the degree to which their scores consistently fall above a threshold performance level (consistency).1 A base score is calculated as a combination of the achievement and improvement scores, and a (total) patient experience domain reimbursement score is calculated by summing the base and consistency scores. For this analysis, the outcomes of interest are the HCAHPS base, consistency, and total patient experience domain scores for the reporting period ending September 30, 2012 (made publicly available in the third quarter of 2013). The patient experience domain score accounts for 30% of the total performance score that all eligible US hospitals receive for VBP reimbursement, making it not only a meaningful measure of patient-reported experiences but one with financial implications for hospitals.

Statistical Analysis To assess the generalizability of the initial sample and the obtained sample, the study team first compared characteristics of these 2 sets of hospitals to themselves and to hospitals nationally as obtained from Hospital Compare. Characteristics include bed size, ownership, academic affiliation, and the presence of 24-hour emergency services. The team also compared the different groups on hospital performance measures, including VBP HCAHPS scores, adherence to clinical guidelines, mortality rates, and financial health. Next, using descriptive statistics, the study team reports responses to individual survey items. Last, the team tests for statistically significant relationships between each survey question and the 3 focal VBP scores. The study team used stepwise multivariable regression where the dependent variables were the VBP scores (obtained from Hospital Compare) and the independent variables (obtained from the survey) were the particular question of interest and the control variables (again obtained from Hospital Compare) that adjusted for the hospital structural characteristics. All analyses were performed with JMP 9.0.2 (SAS Institute, Inc., Cary, NC). This study was reviewed by the Institutional Review Board at the University of North Carolina and was determined not to constitute human subjects research.

Results Characteristics of Hospital Respondents Responses were received from 143 of 416 institutions (response rate, 34.4%). The study team was unable to obtain HCAHPS VBP scores from the Hospital Compare

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Manary et al Table 1.  Characteristics of Study Hospitals and National Sample Median.a

Bed size Ownership (%)  Government  Proprietary  Nonprofit   Teaching affiliation   Emergency services on-site Value-Based Purchasing scores   Base score  Consistency   Total patient experience domain HCAHPS scores   Hospital given a rating of 9 or 10b   Yes, definitely recommend hospitalc   Doctors “always” communicated welld Clinical performance   Heart attack   Heart failure  Pneumonia Mortality   Heart attack   Heart failure  Pneumonia Financial health (%)   Operating margin   Net income Respondent profile (%)   Chief nursing officer   Chief experience/quality officers   Quality improvement professionals (not an officer)   Chief operating officer

Study Sample (n = 126)

National Sample (n = 2848)

186 (34, 100, 325, 832)

148 (24, 81, 268, 703)

14 2 84 37 99

16 21 63 25 96

P Value for Difference

15.1 (12.3, 14.3, 15.9, 17.6) 11.6 (8.6, 10.6, 12.8, 15.7) 11.6 (9.0, 10.7, 13.1, 16.4)

15.1 (12.2, 14.2, 16.1, 18.2) 11.6 (8.7, 10.6, 12.7, 15.2) 11.7 (8.6. 10.6, 13.1. 16.0)

0.8 (–16.7, –3.8, 6.4, 16.4) 2.9 (–15.0, 0.8, 7.7, 17.1)

0.4 (–36.8, –5.4, 6.9, 28.5) 3.9 (–16.5, –0.5, 8.9, 28.1)

.01   .58

Organizational characteristics and patient experiences with hospital care: a survey study of hospital chief patient experience officers.

Beginning in fiscal year 2013, scores based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) constitute 30% of incenti...
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