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Sharpening your survey skills: How practices can measure patient satisfaction

Insurers base their pay-for-performance programs in part on patient satisfaction scores, and CMS will do the same thing. So how should physicians design their surveys?

By — Posted April 18, 2011

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At some point, practice administrator Greg Bush expects to have Medicare surveying patients who go to Gastroenterology Consultants of Greater Cincinnati about their experiences. And, he said, he expects the survey results to become part of what determines the practice's Medicare pay.

Bush said he didn't know exactly what the Centers for Medicare & Medicaid Services had planned for patient satisfaction scores and pay-for-performance but knew enough to try surveying patients first. "I'd rather be ahead of it."

In fact, the Patient Protection and Affordable Care Act requires Medicare to include "an assessment of patient experience and patient, caregiver and family engagement" on Medicare's Physician Compare website by Jan. 1, 2013.

Experts say Medicare is likely to integrate that measurement of patient experience into a pay formula for physicians by 2015.

It already has begun requiring hospitals to report patient survey data to receive full payments. Beginning in 2013, hospitals' pay will depend on patients' reported experiences.

Many medical offices, like the practice Bush helps manage, already are asking patients for feedback. If payers are not already surveying patients and tying the results to payment rates, they will be soon.

Given the amount of potential money hanging in the balance, physicians have a new reason to design a survey themselves or choose a vendor to do it for them, experts said.

How best to do the preemptive surveying depends on a practice's budget, whether the physicians want to ask highly specific questions about the practice rather than standard ones, whether they are interested in benchmarking against physicians across the country, and how closely they are interested in mimicking payers' surveys.

First, physicians or group practices must decide whether to hire a vendor to conduct the surveys and analyze results.

A number of vendors offer online surveys analyzed with national benchmarking data.

Some vendors survey patients using questions similar to those in the survey instrument developed by the Dept. of Health and Human Services for physician offices, called the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey or CG-CAHPS.

But going with a vendor isn't the only way to use CG-CAHPS as a model -- the other option is to write your own survey using the document as a guide.

The practice can decide to conduct the survey either by paper or online.

A free downloadable version of the CG-CAHPS survey is available online and comes with instructions and methodology for analyzing the results.

The practice also could decide to ask its own questions, based purely on what it values and wants to know about.

Increasingly, medical practice Web designers are adding some form of patient survey to practice websites, said Elizabeth Pettrone, president and founder of Practis, a Charlotte, N.C.-based Web design firm that specializes in medical practice websites.

She said vendor-developed surveys were once popular among her clients, but many are turning to their own websites to host custom-written surveys.

"Five or six years ago, it was once out of a blue moon. Now it seems like 30% of them will ask for it," she said. Of the big vendors' sites, she said, "Some doctors liked having the comparative reporting to other physicians in their specialty. The downside is because they need to normalize the data, they have to keep the survey questions the same."

How to design a survey

One way for a practice to prepare for when Medicare administers CG-CAHPS is to start surveying patients independently, using the publicly available template.

The questions on the CG-CAHPS survey were developed with help from the American Medical Association and other interested parties. All questions are answered on a scale of "always" to "never." For example: "In the last 12 months, how often did this doctor show respect for what you had to say?"

Whatever questions physicians ask and whatever templates they choose, experts say, they should strive to make the survey as brief as possible while still eliciting meaningful responses.

That will help with another challenge -- getting surveys back. "The more concise you can make it, the better response rate you're going to have," said Gastroenterology Consultants' Bush.

Pettrone noted, large vendors keep their questions standard for a reason: If it's important to track performance over time, changing the questions significantly every time will make it difficult to identify improvement or decline in scores.

Pettrone suggested that questions be ordered chronologically. Start questions where the visit begins, or even before. How long did it take to find parking? How long was the wait before the patient was seen by a nurse? How did the front desk staff treat the patient? The questions can continue through the visit right to asking about follow-up care.

Physicians designing their own surveys also need to decide what kind of answers they want to elicit -- perception of experience, like the CG-CAHPS survey, or a rating of an experience, like what surveys by consulting firm Sullivan Luallin use. The San Diego-based firm is the preferred vendor of the Medical Group Management Assn.

Co-founder Meryl Luallin said the framing of the questions on the group's surveys is deliberately different from CG-CAHPS.

"Our rating scale is, 'How would you rate this? Excellent, very good, fair or poor?' That's markedly different from asking a patient to try to recall the actual experience they had," she said. "We don't believe a patient's memory going back six or nine months ago is very valid."

How to conduct the survey

Because results become more meaningful with a higher participation rate, better response rates mean better results. Many practices ask patients to visit either an online vendor survey or the practice's website after their appointment.

Experts differ about whether it is a good idea to have patients take a survey while they are in the office. Pettrone said her clients sometimes take an older computer, set it up in the waiting area and bring up the survey online so patients who don't have Internet access at home, or those who prefer to get it out of the way, can answer.

Steve Feldman, MD, PhD, a dermatologist who is CEO of, a Winston-Salem, N.C.-based company that sells online surveys, said some of his customers set up in-office kiosks, though he said, "I worry a bit about whether [patients] can fill it out totally honestly there."

But Pettrone said an in-office kiosk or computer probably is preferable to offering a paper survey, because paper questionnaires are so easily discarded or lost. "It's always a problem -- how do you get that paper back?" she said.

Even if filling out the survey online is easy, persuading patients to do it is another matter.

Alycia Ottesen, director of business development for medical services at South Bend, Ind.-based Press Ganey, which sells survey tools to doctors, said the best incentive is to show patients changes made in response to their feedback by posting information in the waiting area about survey results, and what's different based on their survey answers. The AMA and Press Ganey in October 2010 partnered to create an online patient satisfaction survey service called RealTime. It costs $65 per month for AMA members, $85 for nonmembers.

One way to encourage patients to fill the survey out is to stress how valuable their feedback is, Dr. Feldman said.

"The [physician] asking the patient is a really good way," he said. "Patients are really loyal to [physicians]. They want to do what's recommended. They want to please them."

Why surveying pays off

Every pay-for-performance program is different, as is every practice. And most programs depend on more than patient survey scores, so experts say it's difficult to quantify the financial rewards for surveying patients.

For Sharp-Rees Stealy physicians, for instance, the group of 400 employed physicians in San Diego affiliated with Sharp HealthCare brings in millions of dollars a year in pay-for-performance earnings, said Physician Champion for the Sharp Experience Steve Beeson, MD.

But that's a large group, and California's health insurers had some of the first and most active pay-for-performance programs. Even so, Dr. Beeson pointed out, the benefits of focusing on patient experiences, even the financial ones, extend beyond what payers give a practice with strong scores.

Happy patients will refer friends and relatives to their physicians, which improves market share and saves money on marketing, he said. Though money is what pays the bills, keeping patients coming in the door is paramount, and responding to patient feedback is the best way to retain them, Dr. Beeson said.

And there's the benefit of knowing what patients are thinking, and being able to identify what might improve the way the practice operates and cares for patients.

Practice administrator Bush put it another way: "If you're not going to use your satisfaction survey to fix things, then why bother doing it?"

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Sample survey questions

Physicians can gauge patient satisfaction using their own questions, a template developed by government or nonprofit agencies, or a survey from a vendor. Here are sample questions for some widely used surveys:

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), Agency for Healthcare Research and Quality

Q: In the last 12 months, when you phoned this doctor's office during regular office hours, how often did you get an answer to your medical question that same day?

A: 1. Never 2. Almost never 3. Sometimes 4. Usually 5. Almost always 6. Always

The complete survey and other CAHPS surveys are online (link).

Patient Assessment Survey, Primary Care Physician survey instrument, California Cooperative Healthcare Reporting Initiative

Q: In the last 12 months, how often did this doctor seem informed and up-to-date about the care you got from specialist doctors?

A: 1. Never 2. Almost never 3. Sometimes 4. Usually 5. Almost always 6. Always 7. I did not see any specialist doctors in the last 12 months.

The complete survey and other PAS surveys are online (link).

American Medical Group Assn. Patient Satisfaction Benchmarking Survey

Q: Would you recommend the physician/health care professional you saw to your family and friends?

A: 1. Definitely not. 2.Probably Not. 3. Probably Yes. 4. Definitely Yes.

The complete survey and more information about analyzing results are online (link).

Sources: Agency for Healthcare Research and Quality; California Cooperative Healthcare Reporting Initiative; American Medical Group Assn.

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What to do with survey results

Experts say asking for patients' opinions is only the first step toward improving their experiences. Here's what to do with the feedback:

  • If surveys include physician-specific data, meet with physicians to talk about results.
  • Suggest specific actions in the practice to improve low scores.
  • Follow up with coaching by a trusted colleague.
  • If the practice can afford it, benchmark results with those in the same specialty around the country.
  • Share strong patient satisfaction scores with payers when it comes time to negotiate contracts.
  • Post survey results in the office waiting area and link the result to a specific change the practice has made. If patients said they wanted better waiting room reading, get better magazines and let patients know the change was made in response to their feedback.

Sources: Steve Beeson, MD, Sharp-Rees Stealy; Alycia Otteseon, Press Ganey

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How a group raised its patient satisfaction scores

Physicians at Sharp Rees-Stealy, a group of San Diego-based physicians affiliated with Sharp HealthCare, knew they had a problem. But none of the physicians wanted to admit they were part of it.

Stephen Beeson, MD, a family physician, is "Physician Champion for the Sharp Experience" for the 400-physician group of employed physicians. A decade ago, the group found its patient survey responses in the bottom quartile of scores assembled by South Bend, Ind.-based Press Ganey, which sells and analyzes physician surveys nationwide.

The group's leadership, including Dr. Beeson, began an intensive effort to improve its reputation, win market share and prepare itself for pay-for-performance programs that were based in part on patient satisfaction scores.

Dr. Beeson's job was to train physicians who needed help and provide coaching with the goal of earning the loyalty of patients and improving their experience.

"It was a struggle in the first two years to convince physicians that the survey of patients was a direct measure of what they do for patients in the exam room," he said. "Physicians will tear apart a patient satisfaction tool if they believe sample sizes are inadequate or methodologies are flawed."

First, he said, in response to physician concerns, the group raised the number of patient surveys returned for each physician during the year. When doctors felt more comfortable with the methodology, they trusted the results, Dr. Beeson said.

"We worked with [Press Ganey] to create a tool our physicians could accept," he said. "Once you get to that point, the survey becomes a change instrument, and physicians work hard to make it better."

The group started working on improving patient satisfaction just as its major payers -- Anthem Blue Cross, Health Net, PacifiCare and others -- began using the results of patient assessment surveys in their pay-for-performance programs.

Today, Dr. Beeson said, the incentive payments account for "significant revenue" every year for Sharp. The group in turn puts a portion of each physician's pay at risk depending on individual patient satisfaction performance.

He said the surveys are a "verification tool" the group uses to ensure that patients are having the type of experience Sharp wants them to have.

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External links

Surveys and tools to advance patient-centered care from HHS' Agency for Healthcare Research and Quality (link)

Patient Assessment Survey, California Cooperative Healthcare Reporting Initiative (link)

American Medical Group Assn.'s Patient Satisfaction Benchmarking Survey (link)

Medicare physician compare site for consumers (link)

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