Quality of Care and Patient Satisfaction
Today
Israel De Alba, MD MPH
Clinical Professor
Hospitalist Program
Content
Quality of care today. Why? How?
The patients’ perspective
The doctors’ perspective
Summary and conclusions
Aims
To provide an updated perspective on
factors that impact quality of medical care
and patient satisfaction in the era of
health care reform.
To review data on physician satisfaction
CC: failure to thrive
US health care system
• 1
million physicians
• 20
million health care workers
• 5000
hospitals
• 315
million patients
The traditional model for practicing medicine in the United
States has been obsolete for the past 40 years
Ideal health care
Real health care?
Future of health care in the US?
Current challenges
needed change but…
1. Payment restructuring (ACA, from fee-for-service to restricted compensation based
on outcomes)
•
Bundled payments for services
•
Payment for episode of care (specific condition for a specific period)
•
Physician Quality Reporting System and reimbursement based on metrics
•
Shared savings programs
2. Policy changes
•
ICD 10 the use of the International Classification of Diseases
•
Meaningful Use incentive program (MU2) for electronic health records (EHRs)
•
Accountability Act (HIPAA)
•
Physician Quality Reporting System (PQRS) (reporting on 138 outcome quality measures)
Current challenges
3. Time for seeing patients
• Finding time for patients despite escalating administrative noise
4. Rising cost to implement changes
• Implementation of e-medical records and training of staff
5. Changing requirements for recertification
6. Oversight by multiple agencies: insurance companies, policy makers,
government agencies, patients
7. Health information revolution
8. Emphasis on disease rather than on prevention
Quality of care (Institute of Medicine)
Safe
Avoiding injuries to patients from the care that is supposed to help them.
Effective
Based on scientific knowledge to all who could benefit and refraining from providing services to
those not likely to benefit (avoiding underuse and overuse).
Patient-centered
Respectful of and responsive to individual patient preferences, needs, and values and
ensuring that patient values guide all clinical decisions.
Timely
Reducing waits and sometimes harmful delays for both those who receive and those who give
care.
Efficient
Avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
Equitable
Care that does not vary in quality because of personal characteristics, such as gender,
ethnicity, geographic location, and socioeconomic status.
How are we doing?
Change over time
Safety
slight improvement
2011:
National overall HAC rate: 142 per
1,000 hospital discharges.
2010:
National overall HAC rate 145 per
1,000 hospital discharges
Variation by state, race/ethnicity,
SES
*HAC: Hospital Acquired Conditions
Timeliness
•
Time spent waiting in doctors’ offices, ED
•
Interval between identifying a need and receiving the
service
Outcomes in National Health Quality Report
•
◆ Getting care for illness or injury as soon as wanted.
•
◆ ED waiting times.
•
◆ Timeliness of cardiac reperfusion for heart attack
patients.
Timeliness
Patient centeredness
Outcomes
◆ Patients who reported poor communication at the doctor’s office
◆ Adults who reported poor communication with nurses and doctors at
the hospital.
◆ Provider-patient communication among adults receiving home health
care.
◆ Provider’s involvement of the patient in making treatment decisions.
Patient centeredness
Patient centeredness
HCAHPS: patient experience
• Medicare & Medicaid Services (CMS)
• 27-item survey instrument
• First, national and standardized survey
• Allow objective comparisons of hospitals
• Public reporting creates new incentives for
hospitals to improve quality of care
• Reporting enhances accountability
HCAHPS
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and
Systems) survey is the first national, standardized, publicly reported
survey of patients' perspectives of hospital care.
Contains 18 core questions
communication with nurses and doctors
responsiveness of hospital staff
the cleanliness and quietness of the hospital environment
pain management
communication about medicines
discharge information
overall rating of hospital
would they recommend the hospital
HCAHPS
•
2% deduction if no reporting
•
HCAHPS is used in the calculation of the value-based
incentive payment in the Hospital Value-Based Purchasing
program
•
Random sample of adult inpatients between 48 hours and
six weeks after discharge
•
Survey modes: mail, telephone, mail with telephone followup, or active interactive voice recognition (IVR)
HCAHPS
• English, Spanish, Chinese, Russian and
Vietnamese versions
HCAHPS
UCIMC
PatientsPerspective
How patients define quality? What matters to patients?
Funded: RWJ. N=1000, RDD during June 2014
PatientsPerspective
What is quality?
PatientsPerspective
When choosing a physician?
PatientsPerspective
How do you rate quality of care?
Funded: RWJ
N = 1034 adults
National, phone
• N= 10,000 physicians
• Telephone
• Only physicians with >20 hours/week
• Response rate: 52%, 40%, 67%
Time with
patient
Freedom
decisions
High QoC to all
Job
Satisfied
US
29%
55%
79%
84%
Canada
7%
10%
46%
90%
Norway
7%
12%
59%
90%
• N= 7288
• American Medical Association Physician
Masterfile and surveyed a probability-based
sample of the general US population for
comparison
•
Maslach Burnout Inventory
Burnout and Satisfaction
•
45.8% of physicians reported at least 1 symptom of burnout
•
Highest rates among physicians at the front line (family
medicine, general internal medicine, and emergency
medicine)
•
Compared with working US adults, physicians were more
likely to:
•
Have symptoms of burnout
•
Be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for
both)
Burnout and Satisfaction
•
Highest level of education also related to burnout in
multivariate analysis adjusted for age, sex, relationship
status, and hours worked per week
•
Compared with high school graduates, MD or DO degree
were at increased risk for burnout (odds ratio [OR],
1.36; P < .001)
•
Whereas individuals with a bachelor's degree (OR,
0.80; P = .048), master's degree (OR, 0.71;P = .01), or
professional or doctoral degree other than an MD or DO
degree (OR, 0.64; P = .04) were at lower risk for burnout.
Across the world
Burnout by specialty
Good news
Physician satisfaction/wellness missing
form the quality of care picture
Summary and Conclusions
Quality medical care must be safe, effective, timely, efficient,
equitable and patient centered
The US healthcare system is undergoing needed major
structural changes that deeply impact quality of care,
patients perceptions and physician satisfaction
Patient centeredness is a key component of quality of care
Physician satisfaction/wellbeing should also be considered
as a marker of quality of care