Engage, Collect, Partner: How to Use Patient

Experience of Care Surveys in Your Practice

May 22, 2014

We Want To Hear From You!

Type questions into the Questions Pane at any time

during this presentation

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Patient-Centered Primary Care Institute History and Development

• Launched in 2012

• Public-private partnership

• Broad array of technical assistance for practices at all stages of transformation – Learning Collaboratives

– Website (www.pcpci.org)

– Webinars & Online Learning

• Ongoing mechanism to support practice transformation and quality improvement in Oregon

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Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures • Access to Care

– “Be there when we need you”

• Accountability – “Take responsibility for us to receive the best possible health care”

• Comprehensive Whole Person Care – “Provide/help us get the health care and information we need”

• Continuity – “Be our partner over time in caring for us”

• Coordination and Integration – “Help us navigate the system to get the care we need safely and timely

manner”

• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we our

responsible for our overall health and wellness”

Read more: http://primarycarehome.oregon.gov

PCPCH Model of Care

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Engage, Collect, Partner: How to Use Patient Experience of Care

Surveys in Your Practice

Colleen Reuland, MS - Oregon Pediatric Improvement Partnership Jon Yost, MD – Bay Clinic Pediatrics

Lisa Kranz – Family Medical Group Northeast

Colleen Reuland, MS Director, Oregon Pediatric Improvement Partnership

Instructor, Department of Pediatrics, OHSU

reulandc@ohsu.edu www.oregon-pip.org

Learning Objectives

Understand how the CAHPS CG PCMH provides unique and complementary information to guide medical home improvement efforts

Obtain practical methods a practice can use to meaningfully implement the CAHPS CG PCMH in a way that engages patients, providers and office staff

Learn from primary care practices who have implemented these methods, and the successes and key learnings gathered

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PCPCH Standards that Relate to Patient Experience of Care Surveys

Standard 1.A – In-Person Access o 1.A.1 - PCPCH surveys a sample of its population on satisfaction with in-person access to care. (5

points) o 1.A.2 - PCPCH surveys a sample of its population using one of the Consumer Assessment of

Healthcare Providers and Systems (CAHPS) survey tools on patient satisfaction with access to care. (10 points)

o 1.A.3 - PCPCH surveys a sample of its population using one of the CAHPS survey tools, and meets a benchmark on patient satisfaction with access to care. (15 points)

Standard 6.C – Experience of Care o 6.C.1 - PCPCH surveys a sample of its patients and families at least annually on their experience of

care. The patient survey must include questions on access to care, provider or health team communication, coordination of care, and staff helpfulness. The recommended patient experience of care survey is one of the CAHPS survey tools. (5 points)

o 6.C.2 - PCPCH surveys a sample of its population at least annually on their experience of care using one of the CAHPS survey tools. The patient survey must at least include questions on provider communication, coordination of care, and practice staff helpfulness. (10 points)

o 6.C.3 - PCPCH surveys a sample of its population at least annually on their experience of care using one of the CAHPS survey tools and meets benchmarks on the majority of the domains regarding provider communication, coordination of care, and practice staff helpfulness. (15 points)

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CAHPS, CAHPS Everywhere! Oregon Examples: Using Data to Improve Care?

CAHPS- Health

Plan (HP)

CAHPS- HP with the Children Chronic

Conditions (CCC)

CAHPS CG-Patient-

Centered Medical Home

CAHPS CG PCMH

FED

ERA

L C

MS:

C

HIP

RA

CO

RE

MEA

SUR

E

SET

CAHPS Clinician and Group (CG)

Emphasized in

Oregon Medical Home Standards, Unstandardized Data Collection,

Practices collecting data and doing nothing more

National CAHPS;

CMS Adult and Child Quality Grants; State

Sponsored; CCO Incentive Metric; Several CCOs also collecting through CPCI; Other Efforts

Supported by

CHIPRA Demonstration

Grant for Practices, Q-CORP Effort, CMMI Grant

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What Does CAHPS CG PCMH Mean?

• This stands for: – Consumer Assessment of Healthcare Providers and

Systems (CAHPS- this is the name of the survey) – Clinician and Group (CG- this is a specific version of the

survey for practices) – Patient Centered Medical Home (PCMH- this is a version

of the CG survey with items added to measure aspects of medical homes)

• Survey is provided to a sample of patients who have had a visit in the 12 months – Two versions available:

• Child Version • Adult Version

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CAHPS CG PCMH: Why is this Version Useful for PCPCH

Adult Survey

• Access

• Communication

• Self-Management Support

• Office Staff

• Shared Decision Making

• Adult Behavior

Who gets the survey? A sample of patients who had a visit in the last year Sample is comprised of all patients – not just publicly insured

Child Survey

Access

Communication

Self-Management Support

Office Staff

Child Development

Child Prevention

What does the tool address?

Why is valuable for patient-centered medical homes to use? In general, maps to the components of medical home Provides more information about the content of care 11

CAHPS CG PCMH Administration: Approaches Used by Practices

• In order to be valid, recommended to that a standardized vendor administration is used.

• ADDED to the survey screeners to identify patients with special health care needs (SHCN)

• Spotlight of two OPIP supported practices using different approaches:

• Bay Clinic – Administered by their office – Wasn’t feasible for them to use a survey vendor – Therefore, assisted them in implementing themselves in a way that tried

to minimize (not able to eliminate) biases of in-office administration

• Family Medical Group Northeast – Administered by a Survey Vendor

– Survey administrated by a survey vendor through participation in Tri-State Children’s Health Consortium (TCHIC)

– Oregon Health Authority supported

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OPIP Support to Practices in Using the CAHPS CG PCMH

Two arms of support to support meaningful use by the practice:

1) Methods to use BEFORE and DURING survey administration

2) Methods to use AFTER you get the survey data – how to USE and make it meaningful information

• You will see that the methods describe intentionally

address the Standards 2.C ( Patient and Family Involvement in QI) and Standard 2.D – Quality Improvement

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Tools to Enhance Practice and

Patient Engagement on CAHPS CG PCMH

BEFORE Survey Administration

1. Elevator Speech to Engage the Rest of the Practice: Overview materials on the CAHPS CG PCMH to explain the survey to your office generally

2. Posters to put up in the office and share publicly to give patients a heads up

• This poster could also be distributed through website or Facebook.

Materials to give to staff before the survey to answer questions they may receive

3. Scripts for office staff to use (This could be used now)

4. Text for email from providers to patients

5. Frequently asked question you may get and their answers

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Elevator Speech Slides to Engage

the PRACTICE on the CAHPS CG PCMH

• Editable short slide show that you can use to inform staff of your efforts around CAHPS – What is CAHPS CG PCMH?

– Why are we doing this?

– Topics addressed in the survey

– Things staff might see or use in the practice as part of this effort

– What to expect in the coming months

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Materials to Engage Patients in the CAHPS CG PCMH

Poster to Educate Patients about Survey 16

CAHPS Resources Overview-

POSTERS

• Posters for before and during administration – Undergone readability assessments

and cognitive testing

• Two versions, one for parents, one for patients (different picture and slightly different language)

• Customized with practice name • For placement in waiting and exam

rooms • Addresses concerns from previous

administration – Provides expected timeline for

potential respondents – Lets potential respondents know IT

IS ACTUALLY FOR THE PRACTICE

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CAHPS Resources Overview- Scripts

• Talking points to inform parents and patients of the survey and its importance – Sets for the Provider, and

MA/RN/other staff

• Expresses the importance of feedback to the provider – Clarifies the use of

information for IMPROVEMENT

• Informs parent/patient of relationship to survey vendor

• Reiterates and emphasizes confidentiality

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CAHPS Resources Overview- FAQ

• For use by office staff to answer questions frequently asked by patients: – Who is sponsoring the survey – Purpose of survey – Questions about who should fill it

out – Getting surveys in different

languages – How did I get chosen? – Concerns about coming from a

survey vendor and location – Repeat surveys – How to address certain scenarios

(lost/ruined surveys, what ifs etc.) – Defining terms (PCMH, NCQA, etc) – General questions about the survey

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OPIP Support of Practices

Doing the Survey Themselves

• Coaching and assistance on timing of the survey to reduce (not eliminate) biases of an in-office administration

o Survey administration over a couple of months

o Options for mail-based survey

• Built the survey items into Survey Monkey for the practice staff to ENTER the survey data

o Survey monkey provided item-level responses

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OPIP Support to Practices in Using the CAHPS CG PCMH

AFTER the Survey is Collected

1. Analysis of the data into “bite size” pieces

o Roll up of the item-level data into composite measures that give a “Flag” about what it means

o Analyzing the data by groups of patients

o Distilling the data into strengths and opportunities for improvement

2. Methods to meaningful engage the practice in examining the data and what is MEANS

3. Methods for reporting the findings back to patients and to engage patients as partners in QI

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Example of Survey Data Being Rolled up into “Flags”

Access Communication Child Development Child Prevention Self-Management Office Staff

83.37% 96.73% 60.35% 55.82% 29.33% 93.60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ach

iev

em

en

t S

co

re

Example of OPIP CAHPS CG PCMH Analysis: Range of CAHPS CG PCMH Child Quality Domain Achievement Scores across ECHO Practices

H

H

H H

H

H

L

L

L L

L

L

H = Highest practice score

L = Lowest practice score

Analysis and Facilitation by the Oregon Pediatric Improvement Partnership (OPIP) 22

Item-Level Drivers Within Domain Scores

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Comparison of NCQA PCMH and CAHPS CG PCMH Related to Access

↑↓Statistically significantly higher/lower than State score.

↑

↓

↓

↑

0% 20% 40% 60% 80% 100%

Woodburn Pediatric Clinic

Winding Waters Clinic

St. Luke's Eastern Oregon Medical Associates

Hillsboro Pediatric Clinic

Family Medical Group NE

The Children's Clinic

Childhood Health Associates of Salem

Oregon

T-CHIC

Worse Score Better

NCQA PCMH Element 1B After-Hours Access

↑

↑

0% 20% 40% 60% 80% 100%

Woodburn Pediatric Clinic

Winding Waters Clinic

St. Luke's Eastern Oregon Medical Associates

Hillsboro Pediatric Clinic

Family Medical Group NE

The Children's Clinic Tualatin Pediatric Clinic

The Children's Clinic Portland Pediatric Clinic

Childhood Health Associates of Salem

Oregon

T-CHIC

Worse Score Better

CAHPS CG PCMH After Hours Access

Q19. Usually or always able to get care needed from provider's office during evenings, weekends, or holidays

Practice #1 Practice #2 Practice #3 Practice #4 Practice #5 Practice #6 Practice #7 Practice #8

Practice #1 Practice #2 Practice #3 Practice #4 Practice #5 Practice #6 Practice #7 Practice #8

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Selected “AHA” Moments for Practices Based on CAHPS CG PCMH Data

• Systems and processes don’t always yield the intended consequences

o Access domain findings surprising to a number of practices despite having “open access”

Led to improvements in how hours are communicated to patients

Led to examinations of how patients access the practice (e.g. phone lines) and how it would be more patient centered

o Important differences for distinct groups of kids that get lost in “overall” findings

Many practices doing well overall, but found significant disparities in quality domains by child and respondent characteristics

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Examples of Characteristics by which Variations in the CAHPS CG PCMH Data Quality

Domains were Accessed

Characteristics of Persons Care Being Reported About in

Survey

Children & Youth with Special Health Care Needs

(CYSCHN) Child CAHPS CG PCMH Only

Respondent Characteristics

Ethnicity CYSHCN Age of Respondent

Race Number of consequences Education

Age of Patient Type of Consequences Language survey completed

General Health Status

Mental Health Status

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Variations in ECHO Sites Child CAHPS CG PCMH Findings by Child’s Ethnicity and/or Race

Analysis and Facilitation by the Oregon Pediatric Improvement Partnership (OPIP) 27

CAHPS CG PCMH Findings: Example of Analysis by CYSHCN Screener

T-CHIC Added to the Survey

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CAHPS CG PCMH Findings: Example of Analysis by CYSHCN Screener

T-CHIC Added to the Survey

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Variations in CAHPS CG PCMH Findings by Age of Child

0%

20%

40%

60%

80%

100%

Child Development Child Prevention Self-Management

Ach

ieve

me

nt

Sco

re

CAHPS CG PCMH Quality Domain Achievement Scores For Which There Were Significant Differences by Age of Child

0 up to 5 years 5 years up to 12 years 12 years and up

Analysis and Facilitation by the Oregon Pediatric Improvement Partnership (OPIP) 30

Leveraging the CAHPS CG PCMH to Enhance

Patient Engaging in Quality Improvement:

Reporting the Findings Back to Parents- Why Consider it?

• Patient experience of care data is something patients can understand o Of the quality data that you collect, patients understand survey data o That said, they fill out a lot of surveys and are very unclear how this information is

being used o Particularly in Oregon where various versions of the CAHPS are being used,

important for patients to know what you are doing with it. • If you report the survey findings back to patients, you start to change the culture in a

practice o Visible display to patients that you want to hear them and will use their feedback o Helps to create a culture of transparency around the data o Possible way to find your improvement partner o In ideal world, this would have been done closer to when the survey was

administered

• May increase response rate to the next survey o In personal experiences, observed practices that have done this have obtained

higher response rates the next time o Before the next round of the CAHPS CG PCMH, can use a similar type of poster to

give parents a heads up about the survey coming and why are asking for their input

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Example from Woodburn Pediatrics

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Jon Yost, MD Pediatrician, Bay Clinic Pediatrics

Clinic Spotlight: Bay Clinic Pediatrics

• Patient experience of care – CAHPS CG PCMH (with CYSHN Screener) – Used in-office administration and convenience sample of

patients who came in for a visit – Fielded for Two Months (July-September)

• Methods – Part of department strategy, clinic-wide/cultural commitment

• Healthy competition between providers – Promotion (front desk, waiting rooms, exam rooms) – Administration

• Web-based or paper versions (depending on patient preference) disseminated by PROVIDERS at all visits for a pre-determined interval (2 months)

• In addition, surveys were sent by mail to a subpopulation- CYSHN based on provider gestalt and one subpopulation -ADHD

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OPIP Support of Bay Clinic Pediatrics

• Patient-centered administration – Mapped out process for administering in the office – Created survey administration materials

• Posters for the parent • Scripts for office staff • Letters • Survey monkey version

• QI Coaching – Process for who how data will be reviewed – Process for how improvement opportunities – Levers to use with CCO

• Analysis and reporting – Feedback reports of data

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Planning Your Administration: Outline the Steps and Assign Roles

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37

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We got the survey data….now what?

• Summary reports provided by OPIP – Overall quality of care findings by the domains

in the survey

• Item-level drivers – potential areas of improvement

– Findings by important group

• By provider

• Children and youth with special health care needs

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Example of OPIP CAHPS CG PCMH Analysis: Range of

CAHPS CG PCMH Quality Domain Achievement Scores

across Bay Clinic Providers

H

H H

H H

H

H = Highest provider score

L = Lowest provider score

L

L

L

L

L

L

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Example of OPIP CAHPS CG PCMH Analysis:

Variation in CAHPS CG PCMH Self-Management Domain

Achievement Scores by Bay Clinic Provider

Self-Management Domain Item Provider Average Achievement

Score

Q49. Someone at provider’s office talked to you about

specific goals for your child’s health

Provider #1 57%

Provider #2 68%

Provider #3 33%

Provider #4 39%

Q50. Someone at provider’s office asked you if there are

things that make it hard for you to take care of your

child’s health

Provider #1 34%

Provider #2 35%

Provider #3 4%

Provider #4 22%

Blue text is used to indicate a statistically significant difference between each provider’s average achievement score.

Green-shaded cells indicate the highest score where there is a statistically significant difference in quality.

Analysis and Facilitation by the Oregon Pediatric Improvement Partnership (OPIP) 41

Improvement Opportunities Identified

• Communication: Child Development, Office hours, Imaging results

• Changed work-flow to allow more chart review prior to going into exam room, more deliberate referral tracking

• CCO recently hired care manager for our clinic

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Family Medical Group – NE

Lisa Kranz

Family Medical Group Northeast’s

Use CAHPS CG PCMH

• Part of the Enhancing Child Health in Oregon Learning Collaborative

o http://www.oregon-pip.org/projects/echo.html

o FALL 2012: Through this effort, Oregon Health Authority supported a central

contract with DataStat for the CAHPS CG PCMH administration

Submitted a child and adult survey sample

Support from OHA partners in pressuring ALL Scripts in order to create the sample file pull

o FALL 2014: Administering the survey again

Allows us to understand the impact of our medical home quality improvement activities on the patient experience of care 44

We did the survey…now what?

• Summary report provided by DataStat – Overall quality of care findings – Item-level findings

• ECHO Learning Calls – How to interpret data – Issues to consider

• Summary reports provided by OPIP – “Cliff Notes” summary of the report

• Item-level drivers – potential areas of improvement • The Punchline

– Findings by important groups • By child and respondent characteristics

– Children and youth with special health care needs – Age of the child – Race-ethnicity

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Strengths and Improvement Opportunities Identified

• Areas where we were doing well – Access – care when needed

– Communication

– Office staff

• Areas where we needed improvement – Access – care evenings, weekends, holidays

– Self management

– Child development

– Adult Behavioral Health

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Reporting CAHPS Findings Back to PATIENTS

After the First Round

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Reporting CAHPS Finding Back to PATIENTS

Domains from CAHPS – We would have a moveable arrow to identify current QI focus

Here we would Insert specific things that the practice is trialing, use data and ask for feedback and ideas

Here we are describing the CAHPS and QI that is going on in our practice

How to get involved in our Patient and Family Advisory Group

Information about how to get involved in our PFAC or provide ad hoc suggestions

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QI Efforts Implemented Based on CAHPS

• Efforts focused on ACCESS to care – Overall composite score = 83.7%; drill down, indicated only

50% of patients were able to obtain afterhours care.

– Needed more information on the “why” of not meeting the afterhours needs

– Sent out a survey monkey to our patients (we heard you, now tell us more) – still not understanding the problem

– Took info to our Patient-Family advisors – The “Aha!” moment- (None knew how to contact us afterhours)

– Next step: Updated our brochure, website and scripting for staff following-up on patients seen in ER & ED

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Implementing CAHPS Again!

• Two years later able to use the CAHPS again

– Allows us to examine the impact of our QI efforts on the patient experience of care

• With support from OPIP, enhancing practice and patient engagement BEFORE survey administration

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Patient Engagement for CAHPS Round Two

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Opportunity for Practices to Get Support to Implement the Approaches Presented Today

• http://www.pcpci.org/2014-learning-collaboratives

• Improving Patient Experience of Care collaborative includes:

– CAHPS CG PCMH using a survey vendor (at no cost to the site)

– Practice coaching and support to meaningful engage providers and patients in using the survey.

• Deadline to submit an application is Friday, May 30, 2014,

• Questions: reulandc@ohsu.edu

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What Questions Do You Have?

Type questions into the Questions Pane at any time

during this presentation

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Resources & Thanks!

• http://www.oregon-pip.org

• http://www.pcpci.org/2014-learning-collaboratives

• Thanks!

• Please complete post-webinar survey

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