Performance measurement has too often been plagued by inordinate focus on technical aspects of clinical care—ordering a particular test or prescribing from a class of medication—such that the patient’s perspective of the care received may be totally ignored. Moreover, many patients, even with successful treatment, too often feel disrespected. Patients care not only about the outcomes of care but also and their personal experience with care.
There is marked heterogeneity in the patient experience, and the quality of attention to patients’ needs and values can influence their course, whether or not short-term clinical outcomes are affected. Some patients have rapid recovery of function and strength, and minimal or no symptoms. Other patients may be markedly impaired, living with decreased function, substantial pain, and other symptoms, and with markedly diminished quality of life. It would be remiss to assume that these two groups of patients have similar outcomes just because they have avoided adverse clinical outcomes such as death or readmission.
In recommending a focus on measuring outcomes rather than care processes, we consider surveys or other approaches to obtaining the perspectives of patients on the care they receive to be an essential component of such outcomes. When designed and administered appropriately, patient experience surveys provide robust measures of quality, and can capture patient evaluation of care-focused communication with nurses and physicians [24]. And while patient-reported measures appear to be correlated with better outcomes, we believe they are worth collecting and working to improve in their own right, whether or not better experiences are associated with improved clinical outcomes [25].
We believe that measuring patient experience is not only important because it can facilitate care that improves clinical outcomes, but also because it represents an important outcome in its own right. If our health system is truly to commit itself to the goal of delivering patient-centered care, it requires assessment of patients’ experiences with the care they receive and self-reported health status and functioning—whether or not they are associated with commonly-measured outcomes such as mortality, complications, errors, and avoidable readmissions.
With the growing array of scientifically rigorous surveys of patient experiences with care [26], we now have the capacity to incorporate standardized assessments of that experience into the measurement enterprise, increasing our sensitivity to the detection of differences in the results that are being achieved by provider organizations, assuming that we can adequately take into account baseline differences in patient characteristics.
Given the inevitable gaps in both process and outcome measures for specific areas of clinical care, it is important to realize that patient experience is ubiquitous and can be drawn upon to measure a broad range of performance.
Robert A. Berenson, MD is an institute fellow at the Urban Institute.
Peter J. Pronovost, MD, PhD is the director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, as well as Johns Hopkins Medicine’s senior vice president for patient safety and quality.
Harlan M. Krumholz, MD, is the director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, director of the Robert Wood Johnson Foundation Clinical Scholars program at Yale University, and the Harold H. Hines, Jr. professor of cardiology, investigative medicine, and public health.
The authors thank Lawrence Casalino, MD, PhD, chief of the Division of Outcomes and Effectiveness Research and an associate professor at Weill Cornell Medical College, and Andrea Ducas, MPH and Anne Weiss, MPP of the Robert Wood Johnson Foundation for their helpful comments on this paper. This research was funded by theRobert Wood Johnson Foundation, where the report was originally published.
Notes
24. Manary MP, Boulding, Staelin R, et al., “The Patient Experience and Health Outcomes.” New England Journal of Medicine, 368:201-203, 2013, http://podcast.nejm.org/nejm_audio_interview.xmlt.
25. Sorian R. Measuring, Reporting, and Rewarding Performance in Health Care. New York: The Commonwealth Fund, 2006, www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2006/Mar/Measuring%20%20 (accessed April 2013); Fenton JJ, Jerant AF, Bertakis KD, et al. “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality.” Archives of Internal Medicine, 172(5): 405-411, 2012.
26. Clancy C, Brach C and Abrams M (eds). “Assessing Patient Experiences of Providers’ Cultural Competence and Health Literacy Practices: CAHPS® Item Sets.” Medical Care, 50(9), Supplement 2: i–ii, S1–S79, 2012.
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