quality of care from the patient’s perspective background and introduction of the cahps®...
TRANSCRIPT
Quality of care from the patient’s perspective
Background and introduction of the CAHPS® questionnaires into
the Dutch health and social insurance system
• Diana Delnoij (NIVEL)• Herman Sixma (NIVEL)
Structure of the presentation
Introduction + developments in society Developments in QoC research;
perspectives + ‘state-of-the-art’ Past, present and future of the CAHPS-
approach Concluding remarks + discussion
Developments macro level
technological developments rising expectations + expenditures
in the health care sector health care reforms tendency toward democratization
Developments meso level
professionalization of health care
services rise of organizational structures burocratization of services development of category-specific
patient organizations
Developments micro level
changes in doctor-patient
relationshipconsequences ‘ageing society’changes the family structures the ‘professional’ patient
Developments in society: a summary
Macro level :
- from ‘leadership’ to ‘stewardship’
Meso level :
- from ‘supply’ to ‘demand centered’
Micro level :
- from ‘patient’ to ‘active participant’
insurerinsurerinsurer
consumerconsume
rprovider
insurance market
purchasing market
provider market
The new health care ‘market’
Part 2 :
Quality of care (QoC) from the patient’s perspective; history and developments
“ The key to successful doctor-patient partnerships is recognize that patients are experts too ….. The new emphasis is on shared information, shared evaluation, shared decision making, and shared responsibilities ..…”
(Angela Coulter, BMJ 1999; 319: 719-720)
Different QoC perspectives
health insurers > cost efficiency providers > guidelines + protocols patients > satisfaction + QoC ratings government > legal framework
Four generations QoC research
Patient satisfaction studies (see Linder-
Pelz, 1982 a.o.) Service Quality models (Parasuraman et
al, 1985, 1988) Extended SERVQUAL models (CAHPS,
QUOTE, Picker Instruments a.o.) Future: Performance indicator models
Main characteristics ‘state-of-the-art’ QoC questionnaires
patients involvementqualitative + quantitative methodsshift from ‘satisfaction’ to ‘reports’ QoC = multi-dimensional conceptapplicable in QA and QI studies
“ Questions asking for reports tend to reflect better the quality of care and ar more interpretable and actionable for quality improvement purposes than ratings of satisfaction or excellence ..…”
(Paul Cleary & Susan Edgman-Levitan, JAMA 1997, 278 (19): 1608-12)
Examples of some ‘state-of-the-art’ QoC questionnaires
Responsiveness measures WHO Instruments Picker-Europe (UK)Family of QUOTE instruments (NL)CAHPS Instruments (USA)
What is CAHPS?Consumer Assessment of Health Plan Survey
Questionnaires containing items on patients’:experiences with health care providersexperiences with their insurance companygeneral rating of health care and health
plan
Commissioned by: Agency for Healthcare Research and Quality (AHQR).
Developed by: Harvard Medical School, the RAND corporation, and the American Institutes for Research
Introduction of CAHPS in the Netherlands
• Initiative: Agis (regional public health insurer)
• Translation and validation of three questionnaires:
1. CAHPS Adult Commercial Questionnaire
2. Hospital CAHPS
3. Diabetes questionnaire
CAHPS instruments (example 1)Please answer the questions in this survey about this stay at [FACILITYNAME]. Do not include any other hospital stay in your answers.
YOUR CARE FROM NURSES
1. During this hospital stay, how often did nurses treat you with courtesy and respect?1 Never2 Sometimes 3 Usually4 Always
19. Before giving you the medicine, did hospital staff
describe possible side effects in a way you could understand?1 Yes2 No
CAHPS instruments (example 2)
5. Using any number from 0 to 10 where 0 is the worst possible care and 10 is the best possible care, what number would you give the care you got from all the nurses who treated you?
0 0 Worst possible nursing care 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9
10 10 Best possible nursing care
Translating the CAHPS Adult Commercial Questionnaire
Translation: forward - backward by 2 x 2 translators
Tailored to the Dutch health care system:Absence of nurse practitioners or physician
assistantsdistinction between ER in hospital and out-of-
hours services of GPs
Adaptation to social-cultural values in NL:Question about educational system Use of ethnicity instead of race
Fielding the CAHPS Adult Commercial Questionnaire
Representative sample of 1,000 Agis clients who were insured 6 months prior to sample selection
In November 2003, 977 insured received a mailed questionnaire; 545 responded (56%)
Respondents are significantly older than non-respondents
Respondents are also older than the general Dutch population and in worse health
Validating the CAHPS Adult Commercial Questionnaire
1. Check consistency of the data o.k.
2. Check frequencies and missing values o.k.
3. Check factor structure and reliability o.k.
4. Compare results with other Dutch studies and with the American National CAHPS Benchmarking Database 2003:
This presentation
% of respondents experiencing problems:
0%
20%
40%
60%
80%
100%
Finding apersonaldoctor or
nurse
Getting areferral for a
specialist
Getting careor treatmentyou needed
Waiting forconsent from
theinsurancecompany
NL
USA
Comparison of Dutch data (NL) with American benchmark data (USA): access to care
% of respondents with positive experiences:
0%
20%
40%
60%
80%
100%
staffcourtesy
helpfulstaff
doctorsspendenough
time
doctorslisten
carefully
doctorsexplain
things well
NL
USA
Comparison of Dutch data (NL) with American benchmark data (USA): patient-centered care
Ratings of providers and health plan
0%
20%
40%
60%
80%
100%
NL USA NL USA NL USA NL USA
personaldoctor
specialist health care health plan
9 or 10
7 or 8
0 to 6
Comparison of Dutch data (NL) with American benchmark data (USA): general rating
Translation into consumer information: % consumers who always experience that:
0,00% 20,00% 40,00% 60,00% 80,00% 100,00%
doctors spendenough time
doctors listencarefully
doctors explainthings well
national Agis
Conclusion
Dutch respondents are able to fill out the questionnaire
Results are internally consistent and reliable
Patients’ evaluation of the Dutch and American primary process is strikingly comparable
More research is needed on the external validity in the Dutch context
Major uncertainties
Will insurers really engage in strategic purchasing?If so, is CAHPS-information useful for
them?
Will consumers choose rationally between different insurers?If so, is CAHPS-information useful for
them?
Looking at the future:
results of a national study on quality of home care from the clients perspective;
MDB – model (home care NL)
Analysis of environmental factors that cannot be influenced by a home care institution
Identification of points that can be used to improve efficiency and quality by analysing the structure and nature of the operation
of the best-practice institutions.
Assessment of the quality of care and services by clients
Assessment of the quality of work by staff
Assess efficiency by comparing expenditure
and production
Building Block 1: Efficiency
Building Block 2: Quality of care and services
Assessment of performance by interested parties
Building Block 4:Social evaluation
Building Block 3:Quality of work
Identification of best-practice institutions
Conceptual model for client survey
Communication
Artificial aids
Professional competence
Continuity
Accessibility
Courtesy
Process
Structure
Quality of home care
Autonomy
Data collection
Questionnaires Number %
Gross random survey 56,094 100.0
- could not be delivered 2,675 4.8
- do not receive home care 500 0.9
Net random survey 52,919 100.0
Gross nr. of respondents 25,973 49.1
- declined to participate 920 1.7
- nothing filled in 494 0.9
Net nr. of respondents 24,579 46.5
Process quality on 1 -10 scale
0
0 .5
1
1.5
2
2 .5
3
3 .5
4
4 .5
5
A verag e = 8 .24 Stan d ard d evia tio n = 1 .3
Num
ber o
f Clie
nts
(in th
ousa
nds)
1 -1.5 1.5 -2 2 -2 .5 2 .5 -3 3 -3 .5 3 .5 -4 4 -4 .5 4 .5 -5 5 -5 .5 5 .5 -6 6 -6 .5 6 .5 -7 7 -7.5 7.5 -8 8 -8 .5 8 .5 -9 9 -9 .5 9 .5 -10
N = 24 .4 4 3
Structure quality, 1 – 10 scale
A verag e = 6 .9 7 Stand ard d evia tio n = 1.6 3
1 -1.5 1.5 -2 2 -2 .5 2 .5 -3 3 -3 .5 3 .5 -4 4 -4 .5 4 .5 -5 5 -5 .5 5 .5 -6 6 -6 .5 6 .5 -7 7 -7.5 7.5 -8 8 -8 .5 8 .5 -9 9 -9 .5 9 .5 -100
0 .5
1
1.5
2
2 .5
3
3 .5
4
4 .5
5
Num
ber o
f Clie
nts
(in th
ousa
nds)
N = 24 .5 5 0
QoC ratings 106 home care organizations
6 .5
7.0
7.5
8 .0
8 .5
9 .0
1 6 11 16 21 2 6 31 3 6 41 4 6 51 5 6 61 6 6 71 76 81 8 6 91 9 6 101 10 6 111
R anked b y C lien t Eva lu atio n
A verag e(7.7 3 )
N = 10 6
Overall QoC scores, broken down by size of organization
1
2
3
0
2
4
6
8
10
12
14
N = 10 6
C lien t evalu atio n categ o ry
C ateg o ry o f Size
Num
ber o
f Ins
titut
ions
1 – ab ove-averag e
2 – a ro u n d averag e (7.7 3 )
3 – b elo w average
Main conclusions (1)
Patient views on QoC should be an important topic
for policy makers + health care providers + health
insurers + patients themselves
Standardization and internationalization of
QoC measuring instruments, based on the
CAHPS approach offers new possibilities for QA,
QI and to derive information to facilitate patient choice
Main conclusions (2) Follow-up research on validity, reliability,
‘sensitivity to change’ and discriminating power
of new measuring instruments (such as the
CAHPS-NL instruments) is still necessary
Mesuring QoC from the patients’ perspective
should be a part of an integrated approach (TQM,
MDB, BSC)
Contact details
Herman J. Sixma, PhDNIVELP.O. Box 15683500 BN UtrechtThe Netherlands
Tel.: ++ 31 30 2 729 710Fax.: ++ 31 30 2 729 729E-mail: [email protected]