Ambulatory Care Quality: Physician vs Patient Perceptions
Ambulatory Care Quality: Physician vs Patient Perceptions
Objective If quality improvement interventions, value-based purchasing and/or certification are based on patient assessments, a common definition of quality should be shared by clinicians and patients. The study's objectives were to determine (i) how patients and clinicians define quality care, (ii) in what ways patients' and physicians' definitions differ and (iii) whether patients' definitions vary by ethnicity.
Design We used the critical incident technique to interview participants about behaviors that resulted in office visits being considered either good or poor quality and compared the prevalence of different types of 'quality' behaviors reported to identify commonalities and differences.
Setting Hawaii and Chicago.
Participants A total of 168 patients and 39 clinicians.
Results We developed a taxonomy, comprising 9 major categories and 106 subcategories of behaviors responsible for quality visits. Almost all clinicians and patients agreed that clinical skill, rapport and health-related communication behaviors were key elements. Patients were more likely to report behaviors demonstrating thoroughness in routine examinations, spending enough time with them, engaging them and being treated with courtesy and respect as drivers of a quality office visit than were physicians.
Conclusions Increased clinician awareness of the behaviors that patients believe are the drivers of a quality office visit can help clinicians improve patients' experience of care and experience-based measures of quality.
Measuring the quality of care—as an end in itself and for value-based purchasing—is a fundamental force in health care today. How quality is defined and measured has implications for patients' well-being and physicians' compensation and board certification. Although experts are converging on the technical, administrative and patient-centeredness concepts that define quality at a high level, patients and physicians must reach a common understanding of what defines quality in the daily practice of medicine if quality improvement and value-based purchasing are to work well for all parties.
This is especially so for patient experience of care, which is now widely accepted by payors, accrediting organizations and regulators as a valid component of quality. Specialty societies and certification boards are actively engaged in efforts to measure patient experience, but a high proportion of physicians remain skeptical of its relevance to quality. Physicians must understand the criteria that patients use to assess performance if they are to score well on patient assessments that will be used as pay-for-performance and board certification criteria.
The objective of our research is to determine at the micro level (i) how patients and physicians define quality care, (ii) in what ways patients' definitions differ from physicians' definitions and (iii) whether patients' definitions vary by patient race/ethnicity. With the advent of patient-centered care concepts and the ability to measure patient assessments of health care in consistent ways, clinicians, payors, accrediting organizations and regulators have focused on patient experiences as a complement to clinical measures. Nevertheless, physicians sometimes express skepticism about the value of patient experience data [10] or patient-centered practice. Often this skepticism is based on the assumption that patient assessments relate to the physician's interpersonal skills and not to specific behaviors that represent quality practices. Physicians may only take patient experience data seriously if they believe these data are measuring quality as they understand it. Consequently, this study asked the question: do patients assess the quality of care they receive in ambulatory care settings using the same or different criteria as physicians?
Previous research has examined the differences in physician and patient assessments of health-care encounters as well as differences in patient assessments as a function of patient race/ethnicity. One study found that physicians and patients both commented on listening and explanation skills and length of the visit, but physicians also focused on issues such as visit management and non-verbal behavior. Another study found an agreement that the three most important competencies were technical skill, ethical conduct and effective communication. Differences in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, as a function of patient ethnicity, have been observed. In the CAHPS Health Plan Survey, Spanish language respondents had worse reports of actual health experiences even though their ratings of their personal doctors, specialists, overall health care and health plan were higher than comparable ratings provided by English-speaking respondents. And, in the CAHPS Hospital Survey, in spite of extensive efforts to insure conceptual equivalence in Spanish translations of these instruments, Spanish language respondents continued to provide higher overall ratings. Additionally, their responses to items about specific health experiences were often more positive than those provided by English language respondents. These studies are limited in what they tell us about the underlying criteria used to define the quality in medical encounters. Consequently, our study used the critical incident technique (CIT) to determine if physicians and patients have common or disparate understandings of quality.
The CIT has been used for more than half a century to describe and classify human behaviors in many fields of employment including health care, to assess patient experiences, patient responses to chronic illness and treatment, quality indicators, nurses' perceptions of quality of palliative care [29], surgical training [30], survey and scale development, asthma self-management [33] and adherence to drug treatment regimens. The CIT provides a methodology for collecting descriptions of specific behaviors that are causally related to an outcome of interest, analyzing these descriptions (critical incidents) and developing a comprehensive taxonomy of such behaviors, as well as assessing the reliability and comprehensiveness of that taxonomy.
Abstract and Introduction
Abstract
Objective If quality improvement interventions, value-based purchasing and/or certification are based on patient assessments, a common definition of quality should be shared by clinicians and patients. The study's objectives were to determine (i) how patients and clinicians define quality care, (ii) in what ways patients' and physicians' definitions differ and (iii) whether patients' definitions vary by ethnicity.
Design We used the critical incident technique to interview participants about behaviors that resulted in office visits being considered either good or poor quality and compared the prevalence of different types of 'quality' behaviors reported to identify commonalities and differences.
Setting Hawaii and Chicago.
Participants A total of 168 patients and 39 clinicians.
Results We developed a taxonomy, comprising 9 major categories and 106 subcategories of behaviors responsible for quality visits. Almost all clinicians and patients agreed that clinical skill, rapport and health-related communication behaviors were key elements. Patients were more likely to report behaviors demonstrating thoroughness in routine examinations, spending enough time with them, engaging them and being treated with courtesy and respect as drivers of a quality office visit than were physicians.
Conclusions Increased clinician awareness of the behaviors that patients believe are the drivers of a quality office visit can help clinicians improve patients' experience of care and experience-based measures of quality.
Introduction
Measuring the quality of care—as an end in itself and for value-based purchasing—is a fundamental force in health care today. How quality is defined and measured has implications for patients' well-being and physicians' compensation and board certification. Although experts are converging on the technical, administrative and patient-centeredness concepts that define quality at a high level, patients and physicians must reach a common understanding of what defines quality in the daily practice of medicine if quality improvement and value-based purchasing are to work well for all parties.
This is especially so for patient experience of care, which is now widely accepted by payors, accrediting organizations and regulators as a valid component of quality. Specialty societies and certification boards are actively engaged in efforts to measure patient experience, but a high proportion of physicians remain skeptical of its relevance to quality. Physicians must understand the criteria that patients use to assess performance if they are to score well on patient assessments that will be used as pay-for-performance and board certification criteria.
The objective of our research is to determine at the micro level (i) how patients and physicians define quality care, (ii) in what ways patients' definitions differ from physicians' definitions and (iii) whether patients' definitions vary by patient race/ethnicity. With the advent of patient-centered care concepts and the ability to measure patient assessments of health care in consistent ways, clinicians, payors, accrediting organizations and regulators have focused on patient experiences as a complement to clinical measures. Nevertheless, physicians sometimes express skepticism about the value of patient experience data [10] or patient-centered practice. Often this skepticism is based on the assumption that patient assessments relate to the physician's interpersonal skills and not to specific behaviors that represent quality practices. Physicians may only take patient experience data seriously if they believe these data are measuring quality as they understand it. Consequently, this study asked the question: do patients assess the quality of care they receive in ambulatory care settings using the same or different criteria as physicians?
Previous research has examined the differences in physician and patient assessments of health-care encounters as well as differences in patient assessments as a function of patient race/ethnicity. One study found that physicians and patients both commented on listening and explanation skills and length of the visit, but physicians also focused on issues such as visit management and non-verbal behavior. Another study found an agreement that the three most important competencies were technical skill, ethical conduct and effective communication. Differences in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, as a function of patient ethnicity, have been observed. In the CAHPS Health Plan Survey, Spanish language respondents had worse reports of actual health experiences even though their ratings of their personal doctors, specialists, overall health care and health plan were higher than comparable ratings provided by English-speaking respondents. And, in the CAHPS Hospital Survey, in spite of extensive efforts to insure conceptual equivalence in Spanish translations of these instruments, Spanish language respondents continued to provide higher overall ratings. Additionally, their responses to items about specific health experiences were often more positive than those provided by English language respondents. These studies are limited in what they tell us about the underlying criteria used to define the quality in medical encounters. Consequently, our study used the critical incident technique (CIT) to determine if physicians and patients have common or disparate understandings of quality.
The CIT has been used for more than half a century to describe and classify human behaviors in many fields of employment including health care, to assess patient experiences, patient responses to chronic illness and treatment, quality indicators, nurses' perceptions of quality of palliative care [29], surgical training [30], survey and scale development, asthma self-management [33] and adherence to drug treatment regimens. The CIT provides a methodology for collecting descriptions of specific behaviors that are causally related to an outcome of interest, analyzing these descriptions (critical incidents) and developing a comprehensive taxonomy of such behaviors, as well as assessing the reliability and comprehensiveness of that taxonomy.
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