Title of Outcome Measure (Improvement Target): IT-6.1: Percent Improvement over Baseline
of Patient Satisfaction Scores
Unique RHP outcome identification number(s): 130601104.3.1, 130601104.3.2,
130601104.3.3
Outcome Measure Description:
To achieve improvement under this metric, Providence will engage in project planning during
DY 2. In DY 3, Providence will apply the planning developed in DY 2 in order to determine
baseline rates for future DYs. In DY 4, Providence intends to improve its patient satisfaction
scores by at least 2.5% over the baseline recorded in DY 3 for the following areas: (1) patients’
rating of whether patients are getting timely care, appointments, and information; (2) patients’
rating of how well their doctors communicate; (3) patients’ rating of doctor access to specialist.
In DY 5, Providence intends to improve its patient satisfaction scores by at least 2.5% over the
DY 4 measurement in the same areas.
Process Milestones:
 DY2:
o P-1 – Project planning – engage stakeholders, identify current capacity and
needed resources, determine timelines and document implementation plans
 DY3:
o P-2 – Establish baseline rates
Outcome Improvement Targets for each year:
 DY4:
o IT-6.1: Percent improvement over baseline of patient satisfaction scores—
patient’s rating of whether patient is getting timely care, appointments, and
information—2.5% improvement over DY3
 DY5:
o IT-6.1: Percent improvement over baseline of patient satisfaction scores—
patient’s rating of whether patient is getting timely care, appointments, and
information—2.5% improvement over DY4
Rationale:
The El Paso area faces several major healthcare challenges, including a lack of primary care
capacity, which can result in negative utilization patterns such as ED overutilization. Improper
utilization results in lower levels of patient satisfaction with the care received, since it is not the
level of care or type of care most appropriate to the patient’s condition. This challenge will be
addressed by Providence’s Expand Primary Care Access project (130601104.1.1), and
Providence expects to see an improvement in patient satisfaction as a result of the associated
Category 1 project.
Another challenge which El Paso faces to a greater extent than other regions of the state is the
challenge of providing culturally competent care to the region’s large Hispanic patient
population. A deficiency of proper, culturally-aware communication by physicians, hospital
staff, and other providers will result in lower levels of patient satisfaction. This challenge will be
addressed by Providence’s Enhance Interpretation Services and Culturally Competent Care
project (130601104.1.2), and Providence expects to see an improvement in patient satisfaction
as a result of the associated Category 1 project.
Finally, the El Paso area must address the challenges presented by the serious regional lack of
specialty care capacity. Prompt access to specialty care will make it possible for patients to
better manage their chronic health problems, resulting in better utilization of the resources
available in the El Paso community of providers, and less utilization of expensive and inefficient
healthcare sites such as Emergency Departments. Improper utilization results in lower levels of
patient satisfaction with the care received, since it is not the level of care or type of care most
appropriate to the patient’s condition. This challenge will be addressed by Providence’s Expand
Specialty Care Capacity project (130601104.1.3), and Providence expects to see an
improvement in patient satisfaction as a result of the associated Category 1 project.
Outcome Measure Valuation:
$4,806,840. In determining the value of this outcome measure, Providence considered the
extent to which an improvement in patient satisfaction scores will address the community’s
needs, the population which this improvement will serve, the resources and cost necessary to
realize the improvement, and the improvement’s conformity to the goals of the Waiver
(including supporting the development of a coordinated care delivery system, improving
outcomes while containing costs, and improving the healthcare infrastructure). Specifically, the
valuation of this outcome measure takes into account the fact that patient satisfaction scores in
the identified areas will be a good indicator of whether Providence’s related Category 1
projects are successful in their goals. The valuation of this outcome measure also takes into
account the challenges which Providence will face in maintaining a patient satisfaction survey
system appropriate to the patient populations served.
Tenet plans to implement a similar Category 3 project at its Sierra Providence East Medical
Center location, serving a different geographic area of the city. The disparity in valuation
between this Providence project and the similar Sierra East project is due to the fact that
Providence is a much larger facility than Sierra East (with 508 beds, compared to 110 at Sierra
East) and accounts for 270% more Medicaid and uninsured days than Sierra East.
130601104.3.1, 130601104.3.2,
130601104.3.3
Related Category 1 or 2 Projects::
Starting Point/Baseline:
Year 2
(10/1/2012 – 9/30/2013)
Process Milestone 1 [P-1]: Project
planning—engage stakeholders,
identify current capacity and
needed resources, determine
timelines, and document
implementation plans.
Data Source: Documentation of
project planning
Process Milestone 1 Estimated
Incentive Payment: $567,718
3.IT-6.1
Percent Improvement Over Baseline of Patient Satisfaction Scores
Providence Memorial Hospital
130601104
130601104.1.1, 130601104.1.2, 130601104.1.3
TBD
Year 3
Year 4
Year 5
(10/1/2013 – 9/30/2014)
(10/1/2014 – 9/30/2015)
(10/1/2015 – 9/30/2016)
Process Milestone 2 [P-2]:
Outcome Improvement Target 1
Outcome Improvement Target 2
Establish baseline rates.
[IT-3.1]: Percent improvement
[IT-3.1]: Percent improvement
Data Source: EHR; claims.
over baseline of patient
over baseline of patient
satisfaction scores.
satisfaction scores.
Process Milestone 3 Estimated
Improvement Target: 2.5%
Improvement Target: 2.5%
Incentive Payment: $658,059
improvement over DY3.
improvement over DY4.
Data Source: Patient survey.
Data Source: Patient survey.
Outcome Improvement Target 1
Estimated Incentive Payment:
$1,055,955
Year 2 Estimated Outcome
Year 3 Estimated Outcome
Year 4 Estimated Outcome
Amount: $567,718
Amount: $658,059
Amount: $1,055,955
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $4,806,840
94553.2
Outcome Improvement Target 2
Estimated Incentive Payment:
$2,525,109
Year 5 Estimated Outcome
Amount: $2,525,109