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All medical care is, by definition, focused on patients – but from time to time other considerations seem to get in the way. Hospital routines may be rigid, or doctors may want to do things in ways that make sense for their needs. To keep medical care true to its central purpose, in the 1990s various groups placed a new emphasis on understanding the experiences and perspectives of patients. In a 2009 report called Crossing the Quality Chasm, the U.S. Institute of Medicine defined patient-centered care as: “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”
By now, providing patient-centered care is considered by most experts to be central to high quality health care. With increased acceptance of the patient-centered ideal, many practical issues and questions come to the fore.
How Do We Know What Patients Experience?
Taking patients’ views into account sounds like a good idea, but what is the best way to do it? For decades, researchers and administrators at hospitals and health plans have done surveys of “patient satisfaction.” General questions are posed to many patients, and their responses are tallied to help efforts to improve health care delivery and market health plans and products. But as early as the 1980s, people realized that such surveys used vague and questionable measures of “satisfaction,” and often produced results that were not very useful for improving care.
Thinking about the personal interactions involved in health care, researchers looked for ways to ask patients about things that actually happened (or failed to happen) in their interactions with doctors, nurses, and other health-care workers. Questions about important processes – such as, “Were you told about the purpose of your medication?” – turn out to be less subject to misinterpretation than a general query like “Were you satisfied with your visit to Dr. Smith?” And the results of the concrete questions are certainly more useful to people looking for ways to improve patient experiences and make health care work better.
Building on the new approaches, in 1995, the federal government’s Agency for Healthcare Research and Quality started to develop standardized surveys for assessing the experience of individuals receiving different types of health care. At first, the new surveys focused on patients who visit clinics or doctors’ offices. Now there are additional surveys with questions appropriate to many types of health care situations and patients, including people in hospitals and disabled patients receiving special services at home. Most surveys are available in multiple languages, and have versions appropriate either for adults or for children. The new patient surveys are in the public domain, so anyone can use them. The federal agency that sponsored their creation provides special technical support to help health care providers use the surveys and the valuable information they generate.
What Can be Done?
Surveys of patient experiences are now widely used in the United States to ensure and encourage improved health-care delivery. For example, the use of surveys and their results is required for certain forms of accreditation for health plans; and many Medicaid programs for the poor or disabled use these surveys to evaluate the quality of care provided by doctors and clinics reimbursed by taxpayers. Similarly, the federal government surveys a sample of Medicare beneficiaries each year, and a new survey of patient experiences in hospitals started to be used across the country in 2008. The 2010 health care reform law calls for yet another use of survey results. Starting in October 2012, more than 3,000 U.S. hospitals will have their payments from the government adjusted in part according to how well they do on surveys of patient experiences.
As patient-experience surveys spread, new issues naturally come up. Are the surveys reliable? Researchers have subjected them to all kinds of tests, and can show they do a good job of making meaningful distinctions among clinics, hospitals, and individual health-care providers. That leaves larger questions about fairness and the larger impact of patient-centered practices.
Is It Fair to Compare Different Doctors, Clinics, and Hospitals?
Any time a new measure is developed, people rightly worry that it could be misused. Surveys of patient experiences certainly cannot just be tallied up and turned into “quality scores” that are mechanically applied across the country. After all, what counts as good care depends on the kinds of patients. For example, if patients are mostly very sick, or do not speak English as their native language, it may be more difficult for providers to communicate clearly with them. And different sorts of patients may answer similar questions differently. Younger patients may be more demanding and thus give lower scores than older patients for the same care. To address these issues, researchers and agencies adjust scores to refer to a typical population of patients. This is the only way to fairly compare various doctors, clinics, and hospitals, without penalizing some just because they have patients who are harder to treat or demand more than patients treated elsewhere.
Does Patient-Centered Care Improve Health Care Overall?
Surely it is a good thing for health care to be delivered in ways that are sensitive to the experiences, knowledge, and values of the men, women, and children who need care. Maybe that is enough. Yet numerous rigorous studies have asked whether effective patient-centered care is related to other important outcomes. The results suggest it is. Patients who report specific good experiences have more trust and are less likely to switch physicians or health plans, allowing for more continuity in care. In technical ways, too, patient-centered care performs better. For example, studies have shown that patients treated for a heart attack in hospitals with better patient-centered care have fewer symptoms and are more likely to survive a year later. And patients treated in hospitals that perform well on the surveys are less likely to require readmission in the month after they go home.
Read more about how health care quality is defined and assessed in Paul Cleary and Margaret O’Kane, “Evaluating the Quality of Health Care,” in e-Source: Behavioral and Social Science Research Digital Anthology, edited by J.B. McKinlay and L.D. Marceau (Office of Behavioral and Social Science Research, 2011).