With the final ED – CAHPS survey (The Emergency Department Consumer Assessment of Healthcare Providers and Systems) expected to become mandatory sometime in late 2015 or early 2016, now is the time for hospitals to make sure they have sufficient, in-depth, feedback about patients’ perceptions of their experiences in their emergency department. The survey from CMS will assess information about the patient experience during arrival in the Emergency Department, during care, and after being admitted to an inpatient unit or discharged from the ED.
More specifically, the final surveys will ask questions about how quickly patients receive initial care, the perceived quality and timeliness of communication with nurses and doctors, wait times, medication and pain handling, interpreter services and discharge instructions — plus the overall rating of care and likelihood to recommend the hospital to others. The Centers for Medicare & Medicaid Services (CMS) is still testing the draft surveys.
Similar to HCAHPS on the inpatient side, CMS’s goal in developing the Emergency Department version of CAHPS is to better understand the ED experience from the patient’s perspective, allow for objective comparisons of the care that patients receive, and improve the quality of Emergency Department visits across the country. Likewise, a portion of Emergency Department reimbursement is expected to eventually be tied to the hospital’s ED-CAHPS scores.
The research methods that produce the richest insight into patient satisfaction and the patient experience tend to be qualitative – e.g. mystery shopping, ethnographic studies. Qualitative methods can be messy, harder to analyze and less conclusive than quantitative research, but they often provide abundant, detailed information about systems and behavior not uncovered by quantitative methods alone. When patients tell you in their own words what happened, how they perceived what happened and “why” they felt the way they did, powerful insights and actionable information emerge.
Which Technique Should We Use?
Mystery shopping — Mystery shopping uses incognito “shoppers” posing as real patients to provide detailed feedback about their experiences. The mystery shoppers make surreptitious notes about each interaction as it occurs. Afterwards, they prepare detailed reporting about their experiences. Even a small group of reports can be very useful for uncovering patient expectations and presenting a graphic picture of your strengths and opportunities for improvement.
The kinds of mystery shopping assessments DHA professionals can perform are almost limitless. Those requested most include telephone calls, outpatient, inpatient, ER, clinic and competitor visits. In most cases, the mystery shoppers proceed through the entire inquiry, scheduling, registration, treatment and discharge processes. We’ve even gone up to the point of surgery. Occasionally we have requests for observation only visits, “shadowing,” or pairing mystery shoppers as companions to real patients.
Ethnography — Ethnographic studies depend on one or more observations and interviews conducted by DHA consultants. Ethnography is a relatively long-term, labor-intensive process. It requires consent from carefully chosen participants, sufficient …
In the September 2013 issue of the Allegheny Medical Society Bulletin, Dr. Fred Rubin provides a first-hand account of his experience as a patient in the hospital where he works. He recalls the various tests, procedures, diagnosis and care he received in the Emergency Department and during his 14-day hospital stay.
Dr. Rubin describes the frustration of sleep-disrupting procedures and the helplessness he felt as he lost control of his body. In summarizing the “good and the bad” of his time spent as a patient, he concludes that his overall hospitalization was a “terrible experience.”
Although this likely wasn’t what hospital management wanted to hear, Dr. Rubin’s knowledge of the hospital’s policies and procedures — along with his expertise as a physician — put him in the ideal position to suggest changes to improve the patient experience.
I had a similar opportunity when my husband, a physician, needed emergency care last fall. My background as a hospital executive and a medical mystery shopper enabled me to “see” instances worth reporting to management as I sat by my husband’s side during his visit to the hospital’s Emergency Room, his 17-day hospital stay and discharge to home care. Like Dr. Rubin’s account, there were good and not so good experiences.
It’s great that hospital leaders, managers and staff are doing more rounding on patients. No doubt, rounding helps staff understand their patients better and helps patients understand what’s happening to them and why. But rounding doesn’t always identify what patients or their families are thinking and feeling about the staff, systems and procedures they encounter. Things that your staff might consider trivial may actually create distress and dissatisfaction among others.
Over the many years that we’ve been mystery shopping in hospital Emergency and Outpatient Departments, and on the floors as inpatients, we’ve been able to detect certain “little things” that tend to occur frequently and make patients and families feel disrespected, dissatisfied or unimportant. What follows are the most common:
Today’s hospital leaders are devoting significant time and resources developing approaches to better understand the key drivers of the patient experience and create a culture of service excellence. They’ve encouraged and supported patient advisory councils, focus groups, patient experience committees and hourly rounds on patients. Their staff’s are instituting daily “huddles” to keep care teams informed and focused on patient service. They’re analyzing the costs versus the benefits of patient perks such as enhancing the physical environment and ambience, creating tasty meals, adding valet and concierge services, and extending visiting hours.
What many of these leaders are not doing, however, is taking advantage of a powerful tool that affords them an unmatched view of what patients liked and disliked during random investigations of the hospital. That tool is a mystery shopping report — detailed compilations of individual experiences created by various incognito “patients” from the time of registration or admission all the way through to discharge.
Mystery shopping reports are produced by individuals who have received specialized training on how to think, speak, and behave like a patient. These individuals have fictitious but believable symptoms or complaints. Sometimes a doctor or two is involved in the plan.
The New Year brings a new change in the way DRG reimbursement is distributed. The reimbursement implications are significant, and many hospitals either have lost or will lose much needed federal funding, or collect sizeable incentive payments.
Which outcome will your hospital achieve?
As you know, one factor that determines whether your hospital receives an incentive payment or gets hit with a reduction in DRG reimbursement is inpatient satisfaction. That’s because Medicare’s Value Based Purchasing Program weighs inpatient satisfaction as 30% of a hospital’s performance score.
For this year, up to 1% of DRG reimbursement was at stake at underperforming hospitals. Next year, the percentage increases to 1.25% and increases again in 2017 to 2%. Even if yours is considered a top-performing hospital in its region, its DRG reimbursement may still be at risk because your facility is now being compared to the top 5% of ALL hospitals, with rolling benchmarks.
In anticipation of this change, hospital executives have been retraining staff and revising policies and processes with the goal of improving quality and increasing patient satisfaction at their facilities. Perhaps that’s what you’ve done, too.
Today’s patients are armed and potentially dangerous – but not with handguns or grenades. Their weapon is the Hospital Consumer Assessment of Health Providers and Systems, or HCAHPS. And how patients respond to this standardized national survey could be risky to your facility’s bottom line.
When asked to participate in the HCAHPS survey, many patients are telling it like it is – or at least the way they perceive it to be. But perception is a problem with this tool that promises a more consistent and comparable way to measure patient satisfaction. That’s because perception is subjective, and even though participants can respond with only one of four answers — either “always,” “sometimes,” “usually” or “never” — their responses can still be skewed by their perception of how they and their care were handled.
A few weeks ago I had a medical emergency and ended up being a direct admit to the hospital. I arrived at the Emergency Department in the evening and was discharged 26 hours later with a camera in my small intestine. I’m happy to say that all the testing indicates that there is nothing seriously wrong. It’s just some kind of blood vessel malformation that I’ve probably had all my life.
But the experience hit home an important lesson to me: It’s very different being a “real” patient than a “mystery” patient. As a “real” patient I didn’t feel inclined to make notes of any encounters or events. As a result, I can’t remember everything that happened or who I met during the visit; what went through my head as I was processed through registration, triage, testing, admission to the nursing unit, more testing and the inevitable waiting.
Retail and food service organizations already know that mystery shopping is a proven way to ensure customer satisfaction and increase profits. And the same thing is true in healthcare. Whether you are currently pro or con on the subject, or have never given it any thought, we will arm you with the unbiased information you need to make the right decision about mystery shopping for your organization.
Is There a Downside?