557352

research-article2014

AJMXXX10.1177/1062860614557352American Journal of Medical QualityMoffat-Bruce et al

Commentary

Facing the Tension Between Quality Measures and Patient Satisfaction

American Journal of Medical Quality 2015, Vol. 30(5) 489­–490 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614557352 ajmq.sagepub.com

Susan Moffatt-Bruce, MD, PhD1, Jennifer L. Hefner, PhD, MPH2, and Ann Scheck McAlearney, ScD, MS2,3

The Competing Priorities Within Hospital Value-Based Purchasing

Competing Priorities Felt at the Point of Patient Care

With the passage of the Affordable Care Act authorizing the use of Hospital Value-Based Purchasing (HVBP) contracts, the landscape for hospital reimbursement has again changed. The Centers for Medicare & Medicaid Services (CMS) HVBP program now reimburses hospitals for an increasing number of patient experience elements, including measures of both quality and patient satisfaction. This has led to segmentation of the concept of patient experience. For example, US health care systems tend to have a variety of departments that govern the patient experience. Although all health system leaders are tasked to improve HVBP measures, the involvement of these different leaders perpetuates the problems of a fractured health system as each tries to maximize her or his piece of the reimbursement pie. Thus, although the elements of patient experience may be interconnected, the result of this varied involvement promotes siloed thinking because of competing priorities.

In the face of these competing priorities, the patient is situated in the middle. Rather than reaping the benefit of an expanded focus on patient experience, the reality may be that the patient becomes a victim of the tension that is inherently created. For instance, when considering the need to prevent patient falls—a patient safety measure by anyone’s definition—the goal of fall prevention may be in direct conflict with the goal of improving the patient’s experience when that experience is evaluated on the basis of patient satisfaction scores. In this situation, if a hospitalized patient given a bed alarm feels restrained, his or her experience of care and associated satisfaction may suffer. Frontline staff are aware of this tension; we are often told when debriefing nurses after a patient fall in our hospital that the nurse did not want to infringe on the patient’s rights and felt too much time pressure to have a prolonged discussion with the patient about the need to have both a safe and positive experience. Clearly, while both satisfaction and safety are HVBP measures, nursing staff feel this tension acutely. This may suggest an important opportunity for intervention because improving the hospital-nursing environment has been linked to increases in both quality and patient satisfaction.1

Demonstrating This Problem at One Large Health System Despite the ostensible aim of CMS to be inclusive of all elements of quality, the result of HVBP contracts in most health systems is fragmentation of the quality goal instead of encouraging consideration of a holistic patient experience. Figure 1 presents a series of HVBP pie charts from a large, Midwestern health system where the first author is the Chief Quality and Patient Safety Officer. Although the proportion of the reimbursement pie that is derived from patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems) will remain steady across fiscal years 2013 to 2016, there will be shifts in the other segments of this pie. In 2013, clinical process measures filled out the rest of the pie, but by 2015 the elements of outcomes and efficiency will be added. The reality has been increasing fragmentation of the concept of patient experience, and resultant tension among organizational leaders challenged with maximizing performance for the individual metrics in each leader’s piece of the pie.

Proposed Directions for Health System Managers It is the authors’ view that the pressures of HVBP have created a tension among the organizational priorities of safety, efficiency, and patient satisfaction. We propose 1

The Ohio State University Wexner Medical Center, Columbus, OH Department of Family Medicine, College of Medicine, The Ohio State University, Columbus, OH 3 Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH 2

Corresponding Author: Susan Moffatt-Bruce, MD, PhD, The Ohio State University Wexner Medical Center, 130 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210. Email: [email protected]

Downloaded from ajm.sagepub.com at DREXEL UNIV LIBRARIES on June 4, 2016

490

American Journal of Medical Quality 30(5)

Figure 1.  A series of HVBP pie charts from a large, Midwestern health system. Fiscal years (FYs) 2013 to 2016.

Abbreviations: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; HVBP, hospital value-based purchasing.

that the solution to this problem is to incentivize a cultural shift within health care systems toward patient-centered care (PCC), possibly through including PCC measures in the CMS HVBP formula. There is evidence that PCC improves clinical outcomes and patient experiences, and PCC can be justified on the basis of a business case.2 Yet PCC requires a change in organizational culture from being “provider focused” or “reimbursement focused” to “patient focused,” and this can only occur with the engagement of top leadership and a strategic vision that prioritizes PCC.3 To make this change within their organizations, health system managers should focus on improving meaningful communication between patients and hospital staff, including requiring staff training in PCC and communication skills. Additionally, within the health care delivery system there is an opportunity and need to establish patient expectations. Recent large-scale survey research has found that post visit, patients’ “met” expectations were associated with their satisfaction scores.4 Thus, in practice, in the ambulatory setting patients could be provided with information about what to expect as inpatients, including the needs of the hospital and its staff to balance safety and satisfaction. This approach would be similar to airlines’ efforts to emphasize flight attendants’ roles in flight safety rather than merely providing passenger service on board.

Future Directions for Health Services Research We have presented the above discussion from the perspective of authors with combined decades of experience in the health services field. What is needed now from the research community is study of how health systems across the country are organizing and responding to pressures created by HVBP contracts. Multisite qualitative studies could explore the tension highlighted in this commentary. Furthermore, quantitative studies of publically

available data sets and hospital organizational charts could compare designs across systems and explore associations with HVBP outcomes. The goal of this multimethod research approach would be to develop a best practice framework related to health system organization and HVBP. As health care organizations make the transition to value from volume considerations, we must stay true to the core of our missions and consider the many aspects of patient experience including patient safety, satisfaction, and quality. By integrating and not segregating these elements, we can keep in mind the true, multidimensional experience of patients. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

References 1. Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344:e1717. 2. Luxford K, Safran DG, Delbanco T. Promoting patientcentered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care. 2011;23: 510-515. 3.  Shaller D. Patient-Centered Care: What Does It Take? New York, NY: Commonwealth Fund; 2007. 4. Bowling A, Rowe G, McKee M. Patients’ experiences of their healthcare in relation to their expectations and satisfaction: a population survey. J R Soc Med. 2013;106: 143-149.

Downloaded from ajm.sagepub.com at DREXEL UNIV LIBRARIES on June 4, 2016

Facing the tension between quality measures and patient satisfaction.

Facing the tension between quality measures and patient satisfaction. - PDF Download Free
350KB Sizes 3 Downloads 5 Views