Survey Says …

Patient Satisfaction Scores Tied to Quality, Payment

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Quality Feature — March 2014

By Amy Lynn Sorrel
Associate Editor

What do a busy office environment, comfortable seats, or distant parking lots have to do with quality of care? The link may not be direct or even obvious. But in patients' eyes, these factors could color their entire health care experience and ultimately influence how well they follow their doctors' orders. 

Payers are picking up on that link. Already Medicare ties a portion of hospital pay to patient satisfaction measures, and similar mandates are beginning to hit physicians. That's just one reason, and a big one, that Texas Medical Association leaders say physicians should take the time now to understand the impact of patient satisfaction and evaluate themselves before payers or others do it for them. 

But it's about more than just money, says Ronald S. Walters, MD, an oncologist at MD Anderson Cancer Center in Houston and member of TMA's Council on Health Care Quality. 

"The problem is we tend to focus on only one number, and that's the overall score that's being partly linked to reimbursement. But in that number is a whole bunch of smaller numbers that represent opportunities to improve the experience of care, and our patients are telling that to us," he said. 

Historically, physicians have received high marks — ranging from 80 percent to 90 percent — when they've surveyed their patients about their overall satisfaction with their care. 

"But we have a lot of improvement we can do despite those scores being relatively high, and that's the value of these [patient satisfaction surveys]. They give you some things to look at that you may be blind to," Dr. Walters said.

It's those opportunities that can have a downstream effect on care quality, adds TMA Council on Health Care Quality member Cliff Fullerton, MD. 

The concept is not new but has gained attention since the Institute of Medicine targeted six goals for improving care in its 2001 report, Crossing the Quality Chasm. One of those goals is patient-centered care, of which measuring patient satisfaction is a component, says Dr. Fullerton, a family physician and chief officer of Population Health and Equity at Baylor Scott & White Health in Dallas. It doesn't mean physicians have an obligation to satisfy all of their patients' demands. He says it is, however, a way to gauge patients' perceptions of their care and help close the gap between patients' wants and their actual medical needs.

"We know that unnecessarily giving antibiotics for colds or doing more imaging for low back pain increases patient satisfaction scores. However, giving inappropriate services in order to meet patient expectations can lead to patient harm and prevent them from getting needed care," he said. "If you start with a patient-centered perspective and create tools to allow for a better-informed and shared decision, you create a better experience for the patient; we find that patients are more satisfied when we take the time to give them the information for an informed decision; and the side benefit is better quality, more savings, everything we are trying to accomplish." 

Dr. Fullerton says it may take more time on the front end to sort through patients' preconceptions or behaviors surrounding certain treatments, but building that trust pays off in the long run. 

"In terms of managing a panel of patients, it takes less time once you develop that trust and shared knowledge. The next time you recommend a new drug, the patient says, 'that makes sense'; you come to a quicker decision; and patients don't continue to need as much explanation," he said. 

Hitting the Bottom Line

At a time when health outcomes are a significant focus of the health care system, the role patients' reported experiences play in that equation could affect physicians' bottom line. 

Next year, Medicare penalties will kick in for physician groups of 100 or more that did not start reporting certain quality data as of 2013, under the Physician Quality Reporting System. That includes patient satisfaction measures. (See "Penalties Add Up," May 2013 Texas Medicine, pages 35-39.) Similar PQRS requirements will likely follow for smaller groups, although for now, reporting patient feedback is optional. Eventually, the public will be able to access the information through the Medicare Physician Compare website

Private payers are likely to follow suit, or at least begin using Medicare's public data as a benchmark, says Terri D. Nuss, who oversees Baylor Scott & White's Office of Patient Centeredness. As such information becomes publicly available, everyone from public and private payers to employers will come to the negotiating table expecting it, a trend that has begun on the hospital side.

A recent Medical Group Management Association (MGMA) survey reveals about 10 percent of group practices now factor patient satisfaction survey results into physician compensation. At Baylor Scott & White, 5 percent of physicians' pay depends on those scores, Dr. Fullerton says. 

Click here for more information about MGMA's 2013 Performance and Practices of Successful Medical Groups, which can be purchased. 

Some accreditation organizations also require physicians to report patient satisfaction results. Keller family physician Gregory M. Fuller, MD, says his practice, North Hills Family Medicine, must conduct patient satisfaction surveys as a requirement for maintaining its status as a National Committee for Quality Assurance (NCQA)-certified medical home. Even so, the TMA Council on Health Care Quality member says, it just makes good business sense. Although his practice is not yet under any financial mandates to report patient feedback, he says the process helps the practice stay ahead of that curve by evaluating itself. 

In the exam room, patients may be reluctant to provide feedback about their health care experience. Satisfaction surveys "give patients a neutral site to give you an unbiased opinion so that you can improve," Dr. Fuller said. Sometimes patients are the best, if not only, source for certain information, such as how long they have to wait to be seen, and "as a business, you want to touch base with your clients to find out not only how you can be a better business, but how to provide better medical care." 

While payment is becoming a main driver for collecting patient experience data, Dr. Walters highlights other side benefits: For one, happy patients mean happy practice employees. That translates to lower staff turnover. And, he adds, patients who trust their physicians and staff are more likely to follow instructions, which lessens the practice's workload. They are also more likely to refer other patients, and that increases practice viability. Happy patients also mean lower medical liability risk for the practice.

Survey Tools

Physicians can use a number of tools for collecting patient feedback, whether designing, conducting, and analyzing surveys themselves or hiring a vendor to do it for them. TMA does not endorse a particular vendor, but TMA Director of Clinical Advocacy Angelica Ybarra says the Agency for Healthcare Research and Quality's (AHRQ's) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, used by Medicare, is the industry standard. 

The CAHPS survey is available at no cost. Find it and other patient experience resources on TMA's website. Because the CAHPS surveys are specific to certain care settings, such as hospitals, dialysis units, or physician offices, look for the CAHPS Clinician & Group Surveys (CG-CAHPS), which are applicable to physician practices. MGMA also has a free patient satisfaction benchmarking tool based on the CAHPS survey available online

Christine Crofton, PhD, a CAHPS project officer at AHRQ, says the survey favors the use of what she calls "patient experience" questions over "patient satisfaction" questions. She explains that patient satisfaction questions focus on providing just one type of information — a gross measure of the quality of care given by a medical professional, such as a patient's willingness to recommend a physician on a 1- to 10-point scale or a patient's rating of a health care professional as the 'best' or 'worst' they experienced. 

Patient experience questions elicit more detailed and specific information on particular aspects of care, including: 


  • Physician's communication skills, such as the ability to listen carefully to the patient, explain medication or treatment options in ways the patient understands, and show respect for what the patient has to say;
  • Access to care, including how easy it is for the patient to get an appointment during regular office hours or after office hours, or with a specialist;
  • Courtesy and helpfulness of staff; or
  • Adequacy of discharge information given by hospital staff or instructions for routine care for patients who use dialysis facilities. 


"Patient experience items provide more fine-grained information that is more useful to providers and facilities in making improvements to the care they give, information that is more actionable, understandable, specific, and objective than satisfaction ratings," Dr. Crofton said. 

For example, "satisfaction" surveys might gauge patients' satisfaction with the time they had to wait in the physician's office. Patients who expect to be seen immediately might say a 10-minute wait was unsatisfactory; however, a 10-minute wait may satisfy patients not expecting to be seen within 20 minutes. Both groups "may have the same experience but have very different levels of satisfaction. In contrast, CAHPS surveys ask how often patients were able to be seen within 15 minutes of their appointment time. Practices get actionable feedback that is unbiased by differing patient expectations," she said.

She adds that the American Medical Association, as well as patients, facility staff, and other stakeholders provided input for the CAHPS survey's development and testing.  

TMA leaders say how practices use the results is perhaps more important than the survey itself.

Dr. Fullerton says Baylor Scott & White, with the help of an outside vendor, uses its survey results for quality improvement programs to identify and address gaps in care, such as patient refusal to take medications. For example, one of his colleagues discovered his patient's high cholesterol was not improving because the patient got unsound advice from a hairdresser that such medications were harmful.

"We view it as a quality initiative: It influences employee satisfaction, it influences patient retention, and it influences patient trust," he said. 

To keep costs down, North Hills pulled together what Dr. Fuller describes as a standard patient satisfaction form. The practice surveys its patients every six months, mostly on patients' experiences with the care delivery process, such as wait times and physician and staff friendliness, and then shares that information with physicians and staff to target areas for improvement. 

Going forward, his practice envisions incorporating questions "geared more toward the medical encounter — How did the doctor communicate with you? Did you understand the treatment plan? — because this [information] is going to have to do with outcomes," he said. "If a patient's blood pressure has not improved, but he don't understand what he has to do, that affects the outcome." 

Dr. Walters adds that it's the behaviors the survey questions target that matter. MD Anderson uses the feedback to help address physician behaviors that may influence patients' perceptions of how well physicians care for them, such as how they communicate and listen or whether they sit with their back to the patient.

Proceeding With Caution

For some physician practices, the task is easier said than done.  

Houston internist and TMA Council on Health Care Quality member Lisa Ehrlich, MD, says her four-physician practice plans to incorporate a patient feedback tool in its patient portal. But she's not optimistic that the potential PQRS penalty at stake will justify the expense. Nor is she convinced that patient satisfaction is necessarily tied to quality of care because patients' perceptions can be what she describes as "highly" variable. 

"We don't even know fully what meaningful use [of electronic health records] has done for quality outcomes, and patient satisfaction is even more subjective," she said.

Harris County Medical Society (HCMS) President Elizabeth Torres, MD, echoes those concerns and cautions against putting too much weight on patient satisfaction scores. 

"These scores don't reflect a good outcome or a bad outcome for the patient. They don't say the care was good or the care was bad. It's a perception," she said. "Now that may mean the doctor could communicate better or do things to improve, and care might be better if that happens. But that alone is not an indicator of good care or bad care, a good outcome or a bad outcome. And we have to be careful about how this information is used and make sure it's not the only basis for these [payment] decisions being made."

She adds that HCMS conducted a study of the Centers for Medicare & Medicaid Services (CMS) patient satisfaction mandates and survey vendor market and found that even though the CAHPS survey is free, physicians must follow a rigorous process to use it. For example, practices must use specific templates and disseminate the survey via phone or mail, which has an impact on staff time and practice costs. HCMS also found that as regulatory mandates kick in, more vendors are entering the patient satisfaction market, which eventually could help lower survey costs, Dr. Torres says. 

Meanwhile, current CMS rules do little to help smaller practices with those expenses. For 2014, CMS covers the cost of the CAHPS survey for group practices of 100 or more that are required to report patient satisfaction as part of PQRS. Groups of 25 to 99 physicians also must report PQRS quality data, but providing patient feedback is optional. Those that choose to report it can report fewer PQRS quality measures, but CMS does not cover the cost. For more information on PQRS, visit TMA's resource page

Dr. Fullerton recommends using a third-party vendor to analyze the results if physicians want to reliably and scientifically compare themselves with their peers. But if that option is unaffordable, "every practice needs to have some way of measuring its service," he says, even if the option is a paper questionnaire practices distribute to patients and collect in a box.

While Dr. Walters believes the exercise is worthwhile, he, too, acknowledges that it is not without flaws. Whereas the goal of patient surveys is to get their perspective on the entire care experience, the questionnaires themselves tend to be site-specific — for example, tailored per visit to a hospital or physician office — and do not necessarily provide a comprehensive view of patients' experiences. 

"That's a constrained way to look at what really matters, which is how patients perceive their care and the systems of care across all of their needs," he said, adding that over time, patients could get what he describes as "survey fatigue." 

Nor are such surveys meant to be a technical measure of quality, that is, evidence-based care, Dr. Walters says. Rather, they measure what he calls the "softer side" of the health care experience, which is still an important component of a comprehensive quality measurement strategy.

"I understand patients don't know as much about medicine as we [physicians] do, but this has little to do with medicine. It's very simple: Patients want to know what's wrong with them and what's being done to help them; they want an ounce of care from those delivering it and to leave in better shape than when they arrived. And CAHPS does measure a lot of those things," he said. "Some things may seem trivial to us, but they are not trivial to our patients. And we have to remember that patient experience has a lot of other things attached to it."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Getting Patient Perspective

The American Academy of Family Physicians offers this guidance on conducting patient satisfaction surveys:   


  • Questionnaires should elicit information to help you understand your patients' needs as they relate to your office processes and service level. While you could create the survey yourself, experts recommend using one that has already been tested and validated.
  • Online surveys can be inexpensive and minimize staff burden because no one has to key in survey responses. However, you must provide patients with the URL, and patients must take the initiative to get on the computer and complete the survey.
  • Printed surveys cost more and require more time because someone must key in responses. However, this method may be best if many of your patients don't have computer access.
  • Telephone surveys are time-intensive: Someone must call patients, go through the survey, and key in survey responses. But they allow patient opinions to be probed in-depth.
  • Choose a sampling strategy: You could survey periodically, for example, and distribute questionnaires on a quarterly basis to all patients seen in a given week. Or you could seek feedback continually, for example, by giving the questionnaire to every 10th patient in the office.
  • Distribute surveys in a random fashion, not just to patients who likely had positive experiences, so you can get feedback to help your practice improve.
  • Survey on busy days and slow days because the patient experience may be different.
  • If you decide to survey on your own, without the help of an outside vendor, consider the workload implications of developing, conducting, and analyzing the survey. 
  • If you decide to get outside help, gather information about the companies that interest you, get references from them, and discuss the decision with others in your practice.
  • When you analyze the results, identify problems in office processes and patient service to target for improvement.   


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