Finding the BEST Solution

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Benchmark used to measure patient experience in EDs and immediate care centers.

Introduction

Patients who perceive their providers to be competent, compassionate and good communicators are more satisfied with their care and have better outcomes.[1] Moreover, an excellent patient experience increases caregiver trust and leads to stronger adherence to aftercare recommendations. A 2013 meta-analysis validated the positive relationship between patient satisfaction and safety.[2]

CAHPS

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is the external benchmarking standard for patient satisfaction in all healthcare settings.


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CAHPS was developed in 1995 by the Agency for Healthcare Research and Quality to collect structured patient opinion data and publicly report the results. CAHPS participation became required by the Centers for Medicare and Medicaid Services for a portion of reimbursement after hospitalization in 2005 and ambulatory care visits in 2015. Press Ganey administers the majority of CAHPS surveys.

CAHPS requires only a few hundred surveys to be completed annually to compare similar departments across the US every quarter. A 2017 study demonstrated that the low sampling rate results in excessive variability, so much so that it is common for a department to move up or down a percentile quartile from one month to the next.[3]

Brief Electronic Survey Technology

Brief electronic survey technology (BEST) was designed as an internal benchmarking solution for emergency departments and immediate care centers.


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BEST utilizes short, electronic surveys to collect patient experience data. Automation drives patient-provider information sharing and the staff is alerted to issues and a response module allows reconciliation of wellbeing and service concerns.

A 2019 study detailed the BEST solution and proved that it overcomes the variability limitations of CAHPS.[4] A five-question survey was sent to patients discharged home the day after an emergency department encounter. A 30% response rate permitted granular comparisons of individual provider performance.

After an emergency department or immediate care center encounter, some patients are anxious about symptoms or unsure of the best way for themselves. To provide an optimal patient experience, The Beryl Institute suggests preceding the traditional “How are we doing?” survey questions with “How are you doing?”.[5] By creating a means to ask questions and relay concerns, patients are more confident, and unnecessary returns and admissions are prevented.[6]

BEST satisfies this approach by asking wellbeing questions before service questions. Those that report they are worse (2%) or have aftercare concerns (2%) are contacted by on-duty staff. Service comments (4% compliments and 1% complaints) are reviewed by support staff who can use templates to create a personalized response, and directors are alerted to critical issues.


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External Versus Internal Benchmarking

CAHPS compares similarly sized geographically proximate departments. However, external benchmarking in the context of healthcare delivery is flawed because gaps between expectations and experience establish patient opinions. Expectations are based on prior visits and hearsay. Experience within a certain site will vary from day to day on factors like waiting times, staff member attitude and ease of finding a parking space. CAHPS scores are unlikely to influence decisions on where healthcare services are rendered as patients are most concerned with proximity, care continuity and physician affiliation.

BEST internally benchmarks providers according to satisfaction, productivity and utilization metrics that are statistically valid. To improve their performance, providers must receive that data within a reasonable interval (monthly or quarterly) and be motivated to improve scores incrementally. Directors must relay expectations and hold low performers accountable.

At least 30 completed surveys per provider are the minimum number necessary to make statistically valid comparisons. The BEST survey completion rate is 30%, so if an emergency physician evaluates two patients per hour and sends 75% home, working only two shifts a week is required to make comparisons. In contrast, CAHPS yields about 20 surveys per physician per year, taking 18 months to identify high and low performers.

The bottom line is that external benchmarking with CAHPS defines the current state, and internal benchmarking with BEST leads to the ideal state.

Performance Measurement

The Net Promoter Score (NPS) is a 0-10 rating model is used widely by all types of businesses to assign customers into one of three categories – promoters (9-10), neutrals (7-8) and detractors (0-6).  The NPS is the percentage of promoters minus the percentage of detractors and ranges from -100 to +100. High performers have an NPS exceeding +50.

Detractors may share their dissatisfaction with a dozen people and post negative experiences on social media. Consider that maintaining a 4.3-star rating requires five 5-star ratings to offset each 1-star rating. Increasing promoters and decreasing detractors paves the path to loyalty.

BEST calculates a modified NPS score for each provider. The question “How was your experience with the physician (or nurse)?” is asked, and the mNPS represents the percentage of the top response (very good) minus the percentage of the bottom three responses (average, poor or very poor). The second choice (good) is not factored. Low performers are defined as being one standard deviation below the mean.

BEST assembles satisfaction, productivity and utilization metrics into a balanced scorecard (Figure). Productivity is reflected in relative value units (RVUs) per hour worked where RVUs are estimated by a validated association with the emergency severity index (ESI), and hours are estimated by an algorithm that applies the time of arrival of the first and last patients, and the workload in between. Efficiency is reflected in the turnaround time for discharged patients, and utilization is inferred by the admission rate. Distinct groups, such as nocturnal and pediatric emergency physicians are segregated.

CAHPS v BEST v15 ED focus fig 1 CAHPS v BEST v15 ED focus fig 2

Complaint Management

Complaints should be viewed as golden opportunities to improve relationships and processes.

CAHPS cannot be used to manage patient complaints since comments are sparse and delayed by weeks. Conversely, BEST forwards complaints to staff as soon as they are received, creating an opportunity to convert a detractor into a promoter through awareness, acknowledgment and apology. Most criticisms are minor and can be rapidly addressed with editable templates and electronic responses.

Promptly resolving serious complaints saves a considerable amount of time. Once a formal letter is written, the issue may escalate to senior administration and require adjudication at the Grievance Committee. BEST collects feedback that leads to operational improvements, which benefit future patients.

Conclusion

Gathering actionable feedback soon after an emergency department or immediate care center visit allows for wellbeing checks, complaint management, and awareness of provider and operations improvement opportunities. BEST accomplishes these objectives and improves CAHPS scores.

 

REFERENCES:

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022944/

[2] https://bmjopen.bmj.com/content/3/1/e001570

[3] https://www.ncbi.nlm.nih.gov/pubmed/29269006

[4] https://pxjournal.org/cgi/viewcontent.cgi?article=1376&context=journal

[5] https://www.theberylinstitute.org/blogpost/593434/337680/From-How-are-WE-doing–to-How-are-YOU-doing–A-New-Perspective-for-Experience-Measurement

[6] https://www.annemergmed.com/article/S0196-0644(14)00622-2/fulltext

ABOUT THE AUTHOR

Tom Scaletta, MD, MAAEM, FACEP, CPXP, is past president of the American Academy of Emergency Medicine and president of Auscura, the technology company that developed BEST. Tom is the medical director of emergency and immediate care at Edward Elmhurst Health (Naperville, IL) and regularly works clinical shifts.

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